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Quality Assurance Monitoring Report
Salvare, Inc. d/b/a Dawn Center of Hernando County
Fiscal Year 2018-2019

Florida Coalition Against Domestic Violence
FY 2018-2019 Quality Assurance Final Monitoring Report
Agency: Salvare, Inc. d/b/a Dawn Center of Hernando County
Onsite Dates Monitored: August 27, 2018 – August 30, 2018 (followed by a desk review
through October 8, 2018)
Review Period: November 1, 2017 – October 8, 2018
Release Date of Report: October 8, 2018
Monitoring Team: Suncara S. Jackson, Contract Monitor

NaTasha Bailey Evans, Contract Monitor
Chelsea Massey, Director of Quality Assurance
I. EXECUTIVE SUMMARY
Members of the Florida Coalition Against Domestic Violence (FCADV) monitoring team
conducted the fiscal year 2018-2019 annual quality assurance monitoring of Salvare, Inc.
d/b/a Dawn Center of Hernando County on August 27, 2018 through August 30, 2018 with
a continuation of a desk review through October 8, 2018. The contracts and grants that
were monitored include:
1. Contract Nos. 19-2236-DVS in the amount of $343,701.58, effective July 1, 2018

through June 30, 2019;
2. 18-2236-DVS in the amount of $254,454.89, effective July 1, 2017 through June
30, 2018;
3. 18-2236-CPI-GR in the amount of $75,000.00, effective July 1, 2017 through June
30, 2018;
4. 18-2236-Transportation and Participant Program Needs in the amount of
$16,176.43, effective February 5, 2018 through May 31, 2018;
5. 18-2236-EJ-VOCA in the amount of $74,984.00, effective October 1, 2017 through
September 30, 2018; and
6. 18-2236-VOCA-IFP-LEGAL in the amount of $104,646.00, effective October 1,
2017 through September 30, 2018.
Fiscal, administrative, and program reviews were completed during the monitoring visit.
The preliminary review of findings was discussed during the onsite debriefing held with
the Executive Director and management staff. A formal exit conference was held on
October 8, 2018.

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The Fiscal/Administrative Monitor identified findings related to personnel files, financial
documentation, and participant and/or emergency shelter location identifying information
in fiscal documentation.
The Program Monitor identified findings related to service file documentation, annual fire
safety inspection requirement, annual sanitation inspection requirement, and the shelter
facility.
II. INTRODUCTION
Salvare, Inc. d/b/a Dawn Center of Hernando County is a nonprofit organization

headquartered in Spring Hill, Florida which provides Hernando County with the following
services: emergency shelter, 24-hour hotline, counseling, information and referral, case
management, child assessments, community education, professional training, and outreach.
Salvare, Inc. d/b/a Dawn Center of Hernando County was last monitored through an onsite
review by FCADV on October 3, 2017 through October 6, 2017. During that monitoring,
FCADV identified findings related to noncompliance with fiscal, administrative and
program functions. All issues were resolved.
Salvare, Inc. d/b/a Dawn Center of Hernando County is a Florida Certified Domestic
Violence Center which is certified by the Florida Department of Children and Families
(“The Department”). The last certification review was completed on June 28, 2018 and
Salvare, Inc. d/b/a Dawn Center of Hernando County passed with no corrective action
required. The effective dates of the current certification are July 1, 2018 through June 30,
2019. Per Florida Administrative Code, Chapter 65H-1.012, The Department will annually
renew a center’s certification upon the June 30 expiration date provided The Department
has received a favorable monitoring report from the Coalition.
The accounting firm of Suncoast CPA Group, PLLC issued an unmodified, independent
audit report for the fiscal year ending June 30, 2017, with no findings noted.
III. PURPOSE AND SCOPE
The purpose of the review was to determine whether Salvare, Inc. d/b/a Dawn Center of
Hernando County has complied with the requirements of Chapter 65H-1, Florida
Administrative Code (F.A.C.); Sections 39.905 and 39.908, Florida Statutes; the terms and
conditions of the aforementioned FCADV contracts; the Department Certification
Standards; the FCADV Fiscal Guide; the FCADV Contract Monitoring Frequently Asked
Questions (FAQs); and FCADV Program and Administrative Standards. The review
involved performing tests of compliance including a review of policies and procedures,
administrative records, invoices, financial reports, program reports, and other required
information.

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The monitoring team reviewed the corrective action items identified as a result of the
annual monitoring completed for fiscal year 2017-2018, as well as the Provider Self-
Evaluation Survey and accompanying documentation.
The FCADV contract monitors conduct continuous compliance monitoring on an annual

basis. The scope of the monitoring period includes the first day of the month following the
last monitoring onsite visit through the date of the current onsite monitoring fieldwork. If,
as a result of the monitoring scope, records are selected that were examined during the
previous year’s monitoring process, alternate records are selected and the duplicate records
(with the exception of personnel files and center policies and procedures) are not reviewed
during the current monitoring process.
Financial areas reviewed include, but are not limited to: Policies and Procedures, Audits,
Accounting System, Financial System, Check Review, Match, Payroll, Internal Controls,
Travel, Fixed Assets, Insurance and Bonding, Purchasing, and compliance with the
FCADV Fiscal Guide, FCADV Administrative Standards and Chapter 65H-1, F.A.C., as
well as the applicable provisions of Chapter 39, Florida Statutes.
Administrative areas reviewed include, but are not limited to: Policies and Procedures,
Human Resource Administration, Personnel Files, Assignment and Subcontracts, Data
Security, Inventory, Board Governance and Leadership, Special Provisions, Staffing and
Documentation Procedures, Training, Timely Submission of Deliverables and Required
Reports, and compliance with the FCADV Administrative Standards and Chapter 65H-l,
F.A.C., as well as the applicable provisions of Chapter 39, Florida Statutes.
Program service areas reviewed include, but are not limited to: Shelter Services,
Grievances, Incident Reporting and Response Procedures, Documentation, Policies and
Procedures, Hotline Services, Support Services, Civil Rights Compliance, Participant Risk
Prevention, Participant File Review, Service Delivery Documentation, and compliance
with the FCADV Program Standards, and Chapter 65H-1, F.A.C., as well as the applicable
provisions of Chapter 39, Florida Statutes.
IV. MONITORING METHODOLOGY
The monitoring review was conducted under the following authority sources: Chapter 65H-
1, F.A.C.; Sections 39.9035, 39.905 and 39.908, Florida Statutes; the terms and conditions
of the aforementioned FCADV contracts; the Department Certification Standards; the
FCADV Fiscal Guide; the FCADV Contract Monitoring Frequently Asked Questions
(FAQs); and FCADV Program and Administrative Standards; 45 CFR 74; 45 CFR 92; and
the Office of Management and Budget (OMB) Grants Management Circulars including,
but not limited to, the OMB Uniform Guidance: Administrative Requirements, Cost
Principles, and Audit Requirements for Federal Awards; and Florida Statutes including The
Florida Single Audit Act.

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The methodology used to conduct this contract monitoring included, but was not limited
to:
 Evaluating laws, regulations, and applicable operating procedures.

 Reviewing Salvare, Inc. d/b/a Dawn Center of Hernando County’s contract files and
discussing any pertinent issues with the contract manager.
 Performing an onsite review of fiscal transactions.
 Reviewing pertinent documents and interviewing individuals with relevant information
such as participants, employees, the executive director, and Board members.
 Conducting statistical sampling for fiscal and administrative file reviews at a 90%
confidence level and 10% error rate.
 Conducting statistical sampling for the program file reviews of ten adult resident
service files, ten child resident service files, and ten adult outreach service files. The
files reviewed may be a combination of both open and closed files.
The monitoring instruments utilized to verify contract compliance are maintained in the
center’s file located at the FCADV office. These documents may also be located on the
FCADV website or available from the FCADV upon request. The following is a list of
monitoring instruments used during the review:
 Fiscal/ Administrative Monitoring Tool

 Program Monitoring Tool
 Observation Checklist
 Staff and Board Interview Tools
 Adult Outreach Service File Checklist
 Adult Resident Service File Checklist
 Child Resident Service File Checklist
 Hotline Call Review Checklist
 Civil Rights Compliance Questionnaire
 Motor Vehicle Inspection Checklist
 Payroll Detail Worksheet
 Employee Personnel File Review Checklist
 Direct-Service Volunteer File Review Checklist
 Operating Check Review Checklist
 Credit Card Review Checklist
 Travel Reimbursement Review Checklist
 Emergency Management/Disaster Preparedness Checklist
 Provider Self-Evaluation and Attestation
 VOCA Monitoring Tool
 VOCA Legal Project Service File Review Checklist

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V. FINDINGS AND CORRECTIVE ACTIONS
Finding 1: Personnel Files
Pursuant to the FCADV Contract, Chapter 65H-1.013, F.A.C., and FCADV Administrative
Standards, Salvare, Inc. d/b/a Dawn Center of Hernando County shall maintain a
personnel file for each employee performing services under this contract. The file shall
include at a minimum: service start date; employment application and/or résumé;
reference checks; signed and dated acknowledgment indicating that the employee read and
understood Salvare, Inc. d/b/a Dawn Center of Hernando County’s policies and
procedures relevant to their position pursuant to Chapter 65H-1.013; signed and dated
acknowledgement for receipt of the employee handbook, which includes a confidentiality
statement and drug-free workplace statement (within 60 days of hire); a signed and dated
position description, which specifies the position responsibilities and qualifications; copies
of signed and dated annual performance evaluations; documentation of valid driver’s
license for staff that transport participants; proof of education and/or credentials as
required; W-4 information; documentation of HIV/AIDS Universal Precautions training
(within first year of employment); documentation of advocate-victim privilege
certification; documentation of Anti-Bullying and Anti-Harassment training; “Serving our
Customers who are Deaf or Hard-of-Hearing” certificates of completion; a signed and
dated “Support to the Deaf or Hard-of-Hearing Attestation Form”; and, if 15 or more
employees agency-wide, a signed and dated attestation that the employee is familiar with
the requirements of Section 504, the ADA, and CFOP 60-10, Chapter 4.
Salvare, Inc. d/b/a Dawn Center of Hernando County must also maintain, with respect to
each employee, either in the employee’s personnel file, or in a separate file: records of
training received for each employee, delineating the date and hours of training received;
timesheets and/or activity reports for employees; Department of Homeland Security Form
I-9; documentation of employment eligibility using E-verify; background screening, if
applicable; documentation of Core Competency training within 90 days of hire, if
applicable; documentation of a customized, center-specific data security training (within
90 days of hire); documentation of a signed DCF Security Agreement Form CF 0114 (if
required); documentation of the latest Departmental security awareness training (if
required); and documentation of annual training on implementing the Salvare, Inc. d/b/a
Dawn Center of Hernando County’s emergency management plan.
A review of personnel files revealed the following:
 One of thirteen personnel files did not contain annual signed and dated attestation(s)
regarding Section 504, the ADA, and CFOP 60-10, Chapter 4.
 One of thirteen personnel files did not contain properly executed attestations(s)
regarding Section 504, the ADA, and CFOP 60-10, Chapter 4.
 One of thirteen personnel files did not contain properly executed “Support to the Deaf
or Hard-of-Hearing Attestation Form(s)”.

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 Two of thirteen personnel files did not contain Certificates of Completion for the
"Serving Our Customers who are Deaf or Hard-of-Hearing" online training that were
completed within 60 days of hire. (2nd consecutive year- repeat finding)
 Three of thirteen personnel files did not contain documentation of annual Emergency
Management Plan training. (2nd consecutive year- repeat finding)
 Two of thirteen personnel files did not contain documentation of annual center-
specific Data Security training.
 Two of thirteen personnel files did not contain documentation of center-specific Data
Security training having been completed within 90 days of hire. (2nd consecutive
year- repeat finding)
 One of thirteen personnel files did not contain documentation of annual Anti-
Bullying and Anti-Harassment training.
 One of thirteen personnel files did not contain documentation of Anti-Bullying and
Anti-Harassment training having been completed within 60 days of hire.
 Five of thirteen personnel files did not contain documentation of HIV/Universal
Precautions training having been completed timely.
Corrective Action: In addition to providing documentation to verify that corrections were

made, Salvare, Inc. d/b/a Dawn Center of Hernando County shall, as applicable,
demonstrate an understanding of personnel file requirements, and shall develop a
corrective action plan to ensure that personnel file requirements are completed and
maintained in accordance with the FCADV Contract requirements and Chapter 65H-1.
F.A.C.
Finding 2: Financial Documentation
Pursuant to the FCADV Fiscal Guide, fiscal documentation shall reflect that: the check
and invoice amounts agree with one another; checks are accompanied by the original
invoice(s)/receipt(s); Salvare, Inc. d/b/a Dawn Center of Hernando County records
appropriate coding on disbursements, which shall match coding in the accounting system;
invoices are timely paid by the due date stipulated on the invoice to avoid late fees; items
purchased are reasonable, allowable, and necessary expenditures; all invoices are defaced
upon payment; all disbursements have documented approval by the appropriate level of
management; dual signatures are on checks when required by policy or when the Salvare,
Inc. d/b/a Dawn Center of Hernando County check signer is also the payee; disbursements
are allocated based on the FCADV- approved cost allocation plan for all funds
administered by FCADV; purchasing policies were followed, if applicable; voided checks
shall be clearly marked “VOID” and documented in the accounting system; and
disbursements are made in accordance with F.S. 112.061 (if the purchase relates to travel)
for all funds administered by FCADV.
A review of invoices and financial records revealed the following:
 One of two operating checks did not contain dual signatures as required by agency
policy.

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Corrective Action: Salvare, Inc. d/b/a Dawn Center of Hernando County shall ensure that
invoice and check requirements and documentation are completed and maintained in
accordance with the FCADV Fiscal Guide.
Finding 3: Participant and/or Emergency Shelter Location Identifying Information

in Fiscal Documentation
Chapter 65H-1.016, F.A.C. requires that in order to ensure the safety, confidentiality, and
privacy of persons receiving services, Salvare, Inc. d/b/a Dawn Center of Hernando
County shall safeguard information identifying domestic violence emergency shelters and
center participants as provided in Section 39.908, F.S. Access to any participant-
identifying information shall be limited to staff members who have a legitimate interest in
the case and have a need to know to carry out their job duties.
 Two of twenty-three checks had supporting financial documentation that included the
confidential shelter address, which was not redacted per agency policy.
 One of four credit card statements had supporting financial documentation that
included participant-identifying information, which was not redacted per agency
policy.
Corrective Action: Salvare, Inc. d/b/a Dawn Center of Hernando County shall ensure that
Salvare, Inc. d/b/a Dawn Center of Hernando County’s confidential shelter address and all
information regarding its participants is kept confidential as required by Chapter 65H-
1.016, F.A.C.
Finding 4: Service File Documentation
FCADV Program Standards require that Salvare, Inc. d/b/a Dawn Center of Hernando
County shall open a file for every child receiving center intervention services which
includes an assessment of the child's basic needs. Basic needs shall include, but not be
limited to, immediate needs for food, clothing, shelter or health. Additionally, for children
residing in shelter, an assessment to assist in making appropriate referrals to meet the
child's individual needs shall be conducted within 72 hours of admittance to the shelter.
Services provided to children shall also include age-appropriate safety planning with
children.
FCADV Program Standards require that a consent form must be signed by the
parent/guardian for all services provided to children. Consent forms must be completed
for each child for each service, including, but not limited to, safety planning, assessments,
or for any individual or group activity provided to a child. Both the consent form and the
assessment(s) shall be kept in the child's file. In cases where the parent/guardian does not
grant permission to provide any individual service, or all services and assessments to a

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child, the advocate needs to document this on the consent form. It shall be stated as
declined only to respect the wishes of the parent/guardian and filed in the child's file.
FCADV Program Standards requires that advocacy contacts addressed to individuals or
groups not employed by Salvare, Inc. d/b/a Dawn Center of Hernando County shall not be
initiated without the participant's signed Release of Confidential Information Form. These
contacts shall also apply between centers. The Release of Confidential Information Form
must contain the following: participant's name, specific information to be released, to
whom information is to be given, specific expiration date for release of information,
participant's signature, and revocation statement. The FCADV Contract further requires
that Salvare, Inc. d/b/a Dawn Center of Hernando County shall use the FCADV's approved
Release of Confidential Information Form for the release of confidential participant
information. If Salvare, Inc. d/b/a Dawn Center of Hernando County prefers to use a
substantially similar Release of Confidential Information Form, the alternate form must be
submitted to the FCADV contract manager for approval prior to its use.
FCADV Program Standards require that documentation for service notes shall include
only services provided by the center; all notes shall be entered in chronological order;
correction fluid or corrective tape shall not be used- errors shall be corrected by drawing
one line through it, writing "error" and initialing this change; scheduled appointments
shall not be entered into the participant file; VOCA Relocation applications and supporting
documents, including police reports shall be kept in a separate confidential file; TANF
Eligibility Forms shall be kept in a separate confidential file; participant files shall not
include medical treatment records, psychological assessments or reports, substance abuse
treatment records or any other information from a health care provider; only necessary
facts shall be recorded regarding services delivered; notes shall not contain any diagnosis,
clinical assessments, or advocates' personal opinions, commentary or observations; notes
on one survivor shall not include other participants' names.
Pursuant to the FCADV VOCA-LEGAL Contract, the IFP Project Attorney(s) shall screen
all survivors referred for injunction representation to confirm that the survivor is a victim
of domestic, dating or sexual violence or stalking. The IFP Project Attorney(s) shall
maintain a separate file for each client that includes but is not limited to: copies of all
pleadings and court orders and other court documents related to the client’s case; the
Engagement Agreement; all correspondence with the client, intake forms and releases of
information; detailed logs that indicate the day and amount of time spent on in-person
meetings and/or telephone conversations with the client, witnesses or other persons related
to intake, providing legal advice, case preparation; pleading and court document
preparation; court appearances; and any other work related to the case. Notice of
Completion of Legal Services Provided: The IFP Project Attorney(s) shall provide written
notice to the client of the outcome of the legal services provided and that the provision of
legal services is completed.
FCADV Program Standards require that hotline callers will be immediately assessed for
danger and lethality followed by a safety plan appropriate to their situation.

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A review of participant service files and hotline calls revealed the following:
 Two of ten child resident service files did not contain a basic needs assessment.
 Two of ten adult resident service files did not contain properly executed Release of
Confidential Information form(s).
 Four of ten adult outreach service files did not contain properly executed Release of
 One of ten child resident service files contained unnecessary/inappropriate note(s).
 Four of ten child resident service files contained documents that identified other
participants' names.
 Two of ten VOCA IFP Legal service files did not contain a completed Engagement
Agreement.
 Seven of ten VOCA IFP Legal service files did not contain documentation of written
notice to the client of the outcome of legal services provided and that the provision
of legal services is completed.
 Twelve of fifteen hotline calls did not contain documentation of an assessment for
danger and lethality.
Corrective Action: Salvare, Inc. d/b/a Dawn Center of Hernando County shall develop a
corrective action plan to ensure that service file and hotline requirements are completed
and maintained in accordance with FCADV Program Standards and the FCADV
Contract(s).
Finding 5: Annual Fire Safety Inspection Requirement
In accordance with Chapter 65H-1.015 (2)(i), F.A.C., Salvare, Inc. d/b/a Dawn Center of
Hernando County, shall ensure that an annual fire safety inspection, which conforms to
fire safety standards as determined by each municipality, county, and special district with
fire safety responsibilities as defined in Section 633.025, F.S., is conducted for each shelter
facility. A current inspection shall be maintained in the Salvare, Inc. d/b/a Dawn Center of
Hernando County records and made available for inspection upon request.
A review of shelter facility documents revealed the following:
 The shelter facility had an annual fire safety inspection through its local fire
department; however, the inspection was not timely completed.
corrective action plan which demonstrates an understanding of the statutory requirement
that an annual (within every 365 days) fire safety inspection that conforms to the applicable
fire safety standards must be conducted at each shelter facility according to the
requirements of Chapter 65H-1.015 (2)(i), F.A.C.

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Finding 6: Annual Sanitation Inspection Requirement
In accordance with Chapter 65H-1.015(2)(j), F.A.C., Salvare, Inc. d/b/a Dawn Center of
Hernando County shall ensure that each shelter facility has an annual sanitation
inspection through its local county health department. A current inspection report shall be
maintained in the Salvare, Inc. d/b/a Dawn Center of Hernando County records and made
available for inspection upon request.
 The shelter facility had an annual sanitation inspection through its local county health
that an annual (within every 365 days) sanitation inspection must be conducted at the
shelter facility according to the requirements of Chapter 65H-1.015(2)(j), F.A.C.
Finding 7: Shelter Facility
In accordance with Chapter 65H-1.015(2)(b), F.A.C., all shelter facilities must be in good
repair, free from safety hazards, clean, and free from vermin infestation.
In accordance with Chapter 65H-1015(2)(e), F.A.C., if an outside play area is made

available for children, the area shall be free of debris and broken or dangerous materials,
and shall be routinely checked for safety. Play areas shall be fenced in accordance with
local ordinances to prevent access by children to all water hazards within or adjacent to
outdoor play areas, such as pools, ditches, retention and fish ponds. The outdoor play
area shall have and maintain safe and adequate fencing or walls a minimum of four feet in
height. Fencing, including gates, must be continuous and shall not have gaps that would
allow children to exit the outdoor play area. The base of the fence must remain at ground
level and be free from erosion or build-up to prevent inside or outside access by children
or animals. If the play area is in view of the public, privacy fencing is required.
In accordance with Chapter 65H-1.015(3), F.A.C., the shelter facility shall have telephones
that are centrally located and readily available for staff member and participant use.
Emergency numbers such as emergency medical services, fire department, law
enforcement, hospital, and poison control center shall be posted by each telephone. There
shall be at least one cellular telephone available for use at all times in the event of power
and telephone line outages.
Pursuant to the FCADV Contract, Salvare, Inc. d/b/a Dawn Center of Hernando County’s
Single-Point-of-Contact will ensure that the following three (3) notices are conspicuously
posted near where people enter or are admitted within the agent locations: Interpreter

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Services for the Deaf and Hard of Hearing poster; DCF Non-Discrimination poster; and
Limited English Proficiency poster.
A tour of the shelter facility revealed the following:
 Areas of the shelter facility were in need of repair (missing knobs and/or pulls on
kitchen cabinets; light fixtures/bulbs not working properly; exposed wires near
building entrance; air conditioner not working properly; smoke alarm in garage not
installed properly; hot water faucet inoperable in one bathroom; small hole in privacy
fence surrounding the property; children’s swing set in disrepair).
 The shelter facility was not free of safety hazards (cleaning products in the kitchen
and staff bathroom not contained in an area inaccessible to children; yard
maintenance equipment not contained in an area of the yard inaccessible to children).
(2nd consecutive year- repeat finding)
 The shelter facility did not have an adequate supply of eating utensils for resident
use.
 The shelter’s cellular telephone was not charged and available for use in the event of
power and telephone line outages. (2nd consecutive year- repeat finding)
 Two of the three required notices were not posted near where participants enter or are
admitted to the shelter facility. (2nd consecutive year- repeat finding)
Corrective Action: Salvare, Inc. d/b/a Dawn Center of Hernando County, shall develop a
corrective action plan to ensure that the facility is maintained according to the requirements
of Chapter 65H-1, F.A.C., and FCADV Program Standards.
VI. BOARD MEMBER INTERVIEWS
Salvare, Inc. d/b/a Dawn Center of Hernando County’s Board President and Treasurer were
interviewed during the onsite monitoring visit. The Board members responded to
questions regarding, but not limited to, Board training, policies, practices, survivor
services, Salvare, Inc. d/b/a Dawn Center of Hernando County’s budget and financial
viability, and revenue and resource-generating efforts.
VII. SHELTER FACILITY
The Shelter Observation Monitoring Checklist was used to monitor the physical facilities
of Salvare, Inc. d/b/a Dawn Center of Hernando County. The shelter facility was in good
condition at the time of the onsite monitoring visit with the exception of the specific
issue(s) identified in the "Shelter Facility" finding above.
VIII. CORRECTIVE ACTION PLAN INSTRUCTIONS
Fiscal, administrative, and program reviews may result in findings of noncompliance which
necessitate corrective action. If there is a finding(s) of noncompliance, Salvare, Inc. d/b/a
Dawn Center of Hernando County is required to submit a written response in the form of

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a Monitoring Corrective Action Plan within 10 business days of receipt of the FCADV
Quality Assurance Monitoring Report. The format for the Monitoring Corrective Action
Plan will be provided by the FCADV. The completed Monitoring Corrective Action Plan
shall be submitted electronically to the FCADV via TrackIt in a file labeled “Monitoring
Corrective Action Plan.”

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HOPE Family Services, Inc.

Agency: HOPE Family Services, Inc.
Onsite Dates Monitored: February 11, 2019 – February 15, 2019 (followed by a desk review
through March 7, 2019)
Review Period: September 1, 2017 – March 7, 2019
Release Date of Report: March 8, 2019
Monitoring Team: Catherine Stratis, Contract Monitor

Joy Blocker, Contract Monitor
conducted the fiscal year 2018-2019 annual quality assurance monitoring of HOPE Family
Services, Inc. on February 11, 2019 through February 15, 2019 with a continuation of a
desk review through March 7, 2019. The contracts and grants that were monitored include:

30, 2018;
30, 2018;
5. 19-2213-RI in the amount of $58,000.00, effective July 1, 2018 through June 30,
2019;
2018;
September 30, 2019;
September 30, 2018;
9. 17-213-EJ-VOCA in the amount of $74,983.05, effective November 21, 2016
through September 30, 2017;
10. 19-2213- IFP-LEGAL-VOCA in the amount of $216,600.00, effective October 1,
2018 through September 30, 2019;

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12. 17-2213-VOCA-LEGAL in the amount of $199,292.00, effective November 21,
13. 19-2213-CPI-VOCA in the amount of $58,585.00, effective October 1, 2018
through September 30, 2018; and
through September 30, 2018.
the Chief Executive Officer and management staff. A formal exit conference was held on
March 7, 2019.
The Fiscal/Administrative Monitor identified findings related to personnel file

requirements.
The Program Monitor identified findings related to service file documentation.
II. INTRODUCTION
HOPE Family Services, Inc. is a nonprofit organization headquartered in Bradenton,

Florida which provides Manatee County with the following services: emergency shelter,
24-hour hotline, counseling, information and referral, case management, child assessments,
community education, professional training, and outreach.
HOPE Family Services, Inc. was last monitored through an onsite review by FCADV on
August 8, 2017 through August 11, 2017. During that monitoring, FCADV identified
findings related to noncompliance with fiscal, administrative and program functions. All
issues were resolved.
HOPE Family Services, Inc. is a Florida Certified Domestic Violence Center which is
certified by the Florida Department of Children and Families (“The Department”). The last
certification review was completed on June 29, 2018 and HOPE Family Services, Inc.
passed with no corrective action required. The effective dates of the current certification
are July 1, 2018 through June 30, 2019. Per Florida Administrative Code, Chapter 65H-
1.012, The Department will annually renew a center’s certification upon the June 30
expiration date provided The Department has received a favorable monitoring report from
the Coalition.
The accounting firm of Shinn & Company, LLC issued an unmodified, independent audit
report for the fiscal year ending June 30, 2017, with no findings noted.

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The purpose of the review was to determine whether HOPE Family Services, Inc. has
complied with the requirements of Chapter 65H-1, Florida Administrative Code (F.A.C.);
Sections 39.905 and 39.908, Florida Statutes; the terms and conditions of the
aforementioned FCADV contracts; the Department Certification Standards; the FCADV
Fiscal Guide; the FCADV Contract Monitoring Frequently Asked Questions (FAQs); and
FCADV Program and Administrative Standards. The review involved performing tests of
compliance including a review of policies and procedures, administrative records, invoices,
financial reports, program reports, and other required information.


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to:

 Reviewing HOPE Family Services, Inc.’s contract files and discussing any pertinent
issues with the contract manager.
 Conducting statistical sampling for the program file reviews of adult resident service
files, child resident service files, and adult outreach service files. The files reviewed
may be a combination of both open and closed files.


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 STOP Monitoring Tool
HOPE Family Services, Inc. must maintain, with respect to each employee, either in the
employee’s personnel file, or in a separate file: records of training received for each
employee, delineating the date and hours of training received; timesheets and/or activity
reports for employees; Department of Homeland Security Form I-9; documentation of
employment eligibility using E-verify; background screening, if applicable; documentation
of Core Competency training within 90 days of hire, if applicable; documentation of a
customized, center-specific data security training (within 90 days of hire); documentation
of a signed DCF Security Agreement Form CF 0114 (if required); documentation of the
latest Departmental security awareness training (if required); and documentation of
annual training on implementing the HOPE Family Services, Inc.’s emergency
management plan.
 Two of eighteen personnel files did not contain properly executed Department of
Homeland Security Form I-9(s). (2nd consecutive year- repeat finding)

made, HOPE Family Services, Inc. shall, as applicable, demonstrate an understanding of
personnel file requirements, and shall develop a corrective action plan to ensure that
personnel file requirements are completed and maintained in accordance with the FCADV
Contract requirements and Chapter 65H-1. F.A.C.

Page 6 of 8

groups not employed by HOPE Family Services, Inc. shall not be initiated without the
participant's signed Release of Confidential Information Form. These contacts shall also
apply between centers. The Release of Confidential Information Form must contain the
following: participant's name, specific information to be released, to whom information is
to be given, specific expiration date for release of information, participant's signature, and
revocation statement. The FCADV Contract further requires that HOPE Family Services,
Inc. shall use the FCADV's approved Release of Confidential Information Form for the
release of confidential participant information. If HOPE Family Services, Inc. prefers to
use a substantially similar Release of Confidential Information Form, the alternate form
must be submitted to the FCADV contract manager for approval prior to its use.
A review of participant service files revealed the following:
 Four of ten child resident service files did not contain a signed consent for each
service provided.
 Eight of ten adult resident service files did not contain properly executed Release of
 Seven of ten adult outreach service files did not contain properly executed Release of
 Four of ten adult resident service files contained service note corrections that were
not completed by drawing a line through it, writing"error", and initialing the change.
 Three of ten adult outreach service files contained service note corrections that were
 One of ten child resident service files contained service note corrections that were

Page 7 of 8
 Seven of ten child resident service files contained documents that identified other
 One of fifteen hotline calls did not contain documentation of an assessment for danger
and lethality.
 One of fifteen hotline calls did not contain documentation of safety planning.
Corrective Action: HOPE Family Services, Inc. shall develop a corrective action plan to
ensure that service file requirements are completed and maintained in accordance with
Section 39.908, F.S., FCADV Program Standards and the FCADV Contract.
HOPE Family Services, Inc.’s Board President and Treasurer were interviewed during the
onsite monitoring visit. The Board members responded to questions regarding, but not
limited to, Board training, policies, practices, survivor services, HOPE Family Services,
Inc.’s budget and financial viability, and revenue and resource-generating efforts.
of HOPE Family Services, Inc. The shelter facility was in good condition at the time of
the onsite monitoring visit.
necessitate corrective action. If there is a finding(s) of noncompliance, HOPE Family
Services, Inc. is required to submit a written response in the form of a Monitoring
Corrective Action Plan within 10 business days of receipt of the FCADV Quality
Assurance Monitoring Report. The format for the Monitoring Corrective Action Plan will
be provided by the FCADV. The completed Monitoring Corrective Action Plan shall be
submitted electronically to the FCADV via TrackIt in a file labeled “Monitoring Corrective
Action Plan.”

Page 8 of 8
Peace River Center for Personal Development, Inc.

Agency: Peace River Center for Personal Development, Inc.
Onsite Dates Monitored: April 9, 2019 – April 12, 2019 (followed by a desk review through
May 6, 2019)
Review Period: April 1, 2018 – May 6, 2019
Release Date of Report: May 6, 2019

conducted the fiscal year 2018-2019 annual quality assurance monitoring of Peace River
Center for Personal Development, Inc. on April 9, 2019 through April 12, 2019 with a
continuation of a desk review through May 6, 2019. The contracts and grants that were
monitored include:

30, 2018;
30, 2018; and
4. 20-2218-GTEA in the amount of $288,933.00, effective December 15, 2017
the Executive Director and management staff. A formal exit conference was held on May
6, 2019.
The Fiscal/Administrative Monitor identified findings related to direct-service volunteer

files and personnel files.
The Program Monitor identified findings related to service file documentation, notification
of exceptions to confidentiality, annual sanitation inspection requirement, and staffing and
privilege.

Page 2 of 12
II. INTRODUCTION
Peace River Center for Personal Development, Inc. is a nonprofit organization

headquartered in Lakeland, Florida which provides Hardee, Highlands and Polk counties
with the following services: emergency shelter, 24-hour hotline, counseling, information
and referral, case management, child assessments, community education, professional
training, and outreach.
Peace River Center for Personal Development, Inc. was last monitored through an onsite
review by FCADV on March 13, 2018 through March 16, 2018. During that monitoring,
FCADV identified findings related to noncompliance with administrative and program
functions. All issues were resolved.
Peace River Center for Personal Development, Inc. is a Florida Certified Domestic
(“The Department”). The last certification review was completed on August 17, 2018 and
Peace River Center for Personal Development, Inc. passed with no corrective action
required. The effective dates of the current certification are August 6, 2018 through June
30, 2019. Per Florida Administrative Code, Chapter 65H-1.012, The Department will
annually renew a center’s certification upon the June 30 expiration date provided The
Department has received a favorable monitoring report from the Coalition.
The accounting firm of CliftonLarsonAllen, LLP issued an unmodified, independent audit

report for the fiscal year ending June 30, 2018, with no findings noted.
The purpose of the review was to determine whether Peace River Center for Personal
Development, Inc. has complied with the requirements of Chapter 65H-1, Florida
information.


Page 3 of 12
to:

 Reviewing Peace River Center for Personal Development, Inc.’s contract files and

Page 4 of 12

 DOJ/Other Monitoring Tool
Finding 1: Direct-Service Volunteer Files
Standards, Peace River Center for Personal Development, Inc. shall maintain a personnel
file for each direct-service volunteer performing services under this contract. The file shall
include at a minimum: direct-service start date; a signed and dated position description,
which specifies the position responsibilities and qualifications; documentation of
advocate-victim privilege certification; a signed and dated acknowledgment indicating
that the volunteer read and understood Peace River Center for Personal Development,

Page 5 of 12
Inc.’s policies and procedures relevant to their volunteer duties pursuant to Chapter 65H-
1.013; and a signed and dated confidentiality statement and drug-free workplace statement
(within 60 days of direct-service start date).
Peace River Center for Personal Development, Inc. must also maintain, with respect to
each direct-service volunteer, either in the volunteer’s personnel file, or in a separate file:
records of training received for each volunteer, delineating the date and hours of training
received, to include, but not be limited to, a customized, center specific data security
training, Emergency Management Plan training, Anti-Bullying and Anti-Harassment
training and 16 hours of in-service training; timesheets and/or activity reports for
volunteers; and documentation of Core Competency training within 90 days of the direct-
service start date, if applicable.
A review of direct-service volunteer files revealed the following:
 One of two direct-service volunteer files did not contain a direct-service start date.
 Two of two direct-service volunteer files did not contain signed and dated position
description(s).
 One of two direct-service volunteer files did not contain documentation of Core-
Competency training having been completed within 90 days of direct-service start
date.
 One of two direct-service volunteer files did not contain documentation of 16 hours
of annual in-service training.
 One of two direct-service volunteer files did not contain documentation of annual
Emergency Management Plan training.
center-specific Data Security training.
 One of two direct-service volunteer files did not contain documentation of center-
specific Data Security training having been completed within 90 days of direct-
service start date.
Anti-Bullying and Anti-Harassment training.
 One of two direct-service volunteer files did not contain documentation of Anti-
Bullying and Anti-Harassment training having been completed within 60 days of
direct-service start date.

made, Peace River Center for Personal Development, Inc. shall also, as applicable,
demonstrate an understanding of direct-service volunteer file requirements, and shall
develop a corrective action plan to ensure that direct-service volunteer file requirements
are completed and maintained in accordance with the FCADV Contract requirements and
Chapter 65H-1, F.A.C.

Page 6 of 12
Standards, Peace River Center for Personal Development, Inc. shall maintain a personnel
file for each employee performing services under this contract. The file shall include at a
minimum: service start date; employment application and/or résumé; reference checks;
signed and dated acknowledgment indicating that the employee read and understood Peace
River Center for Personal Development, Inc.’s policies and procedures relevant to their
position pursuant to Chapter 65H-1.013; signed and dated acknowledgement for receipt
of the employee handbook, which includes a confidentiality statement and drug-free
workplace statement (within 60 days of hire); a signed and dated position description,
which specifies the position responsibilities and qualifications; copies of signed and dated
annual performance evaluations; documentation of valid driver’s license for staff that
transport participants; proof of education and/or credentials as required; W-4
information; documentation of HIV/AIDS Universal Precautions training (within first year
of employment); documentation of advocate-victim privilege certification; documentation
of Anti-Bullying and Anti-Harassment training; “Serving our Customers who are Deaf or
Hard-of-Hearing” certificates of completion; a signed and dated “Support to the Deaf or
Hard-of-Hearing Attestation Form”; and, if 15 or more employees agency-wide, a signed
and dated attestation that the employee is familiar with the requirements of Section 504,
the ADA, and CFOP 60-10, Chapter 4.
Peace River Center for Personal Development, Inc. must also maintain, with respect to
each employee, either in the employee’s personnel file, or in a separate file: records of
required); and documentation of annual training on implementing the Peace River Center
for Personal Development, Inc.’s emergency management plan.
 One of seventeen personnel files did not contain acknowledgement(s) for receipt of
the employee handbook, which includes a drug-free workplace statement, that was
signed and dated within 60 days of hire.
 One of seventeen personnel files contained documentation of employment eligibility
verification using E-verify that was not completed timely.
 Four of seventeen personnel files did not contain documentation of Core-
Competency training having been completed within 90 days of hire.
 One of seventeen personnel files did not contain documentation of advocate-victim
privilege registration having been completed within 30 days of hire.

Page 7 of 12
 One of seventeen personnel files did not contain attestation(s) regarding Section 504,
the ADA, and CFOP 60-10, Chapter 4 that were signed and dated within 60 days of
hire.
 One of seventeen personnel files did not contain "Support to the Deaf or Hard-of-
Hearing Attestation Form(s)" that were signed and dated within 60 days of hire.
 Four of seventeen personnel files did not contain documentation of annual center-
specific Data Security training.
 Nine of seventeen personnel files did not contain documentation of center-specific
Data Security training having been completed within 90 days of hire.
 Seven of seventeen personnel files did not contain documentation of Anti-Bullying
and Anti-Harassment training having been completed within 60 days of hire.

made, Peace River Center for Personal Development, Inc. shall, as applicable, demonstrate
an understanding of personnel file requirements, and shall develop a corrective action plan
to ensure that personnel file requirements are completed and maintained in accordance with
the FCADV Contract requirements and Chapter 65H-1. F.A.C.
FCADV Program Standards require that documentation for counseling and/or service
management for each shelter resident housed 72 hours or more and each non-resident who
has received two (2) or more separate counseling sessions will contain at least:
demographic data, lethality assessment, documentation that an individualized safety plan
was conducted, description of the abuser, individualized service delivery plan, child
assessment (if applicable).

groups not employed by Peace River Center for Personal Development, Inc. shall not be
initiated without the participant's signed Release of Confidential Information Form. These
contacts shall also apply between centers. The Release of Confidential Information Form
must contain the following: participant's name, specific information to be released, to
whom information is to be given, specific expiration date for release of information,
participant's signature, and revocation statement. The FCADV Contract further requires
that Peace River Center for Personal Development, Inc. shall use the FCADV's approved
Release of Confidential Information Form for the release of confidential participant

Page 8 of 12
information. If Peace River Center for Personal Development, Inc. prefers to use a
substantially similar Release of Confidential Information Form, the alternate form must be
submitted to the FCADV contract manager for approval prior to its use.
FCADV Program Standards require that participants must be notified that an advocate
may release confidential information about participants without written consent in the
following circumstances: (a) reporting child abuse, (b) summoning emergency services,
such as medical personnel in a medical emergency; firefighting personnel in a fire
emergency; law enforcement with a search warrant or a criminal arrest warrant that
alleges the person or object being sought is located at the shelter; law enforcement when
the information being disclosed is directly related to a participant's commission of a crime
or threat to commit a crime on the premises of the shelter, (c) maintaining safety and health
standards of shelter facilities.
FCADV Program Standards require that Peace River Center for Personal Development,
Inc. must document attempts to provide an exit interview with each participant prior to
their departure from the domestic violence shelter.
 Four of ten adult resident service files did not contain a lethality assessment that was
completed within 72 hours of admittance to shelter. (2nd consecutive year- repeat
finding)
 Five of ten child resident service files did not contain a signed consent for each
service provided.
 One of ten adult resident service files did not contain properly executed Release of
Confidential Information form(s). (2nd consecutive year- repeat finding)
 Six of ten adult outreach service files did not contain properly executed Release of

Page 9 of 12
 One of ten adult outreach service files did not contain documentation that the
participant received Notification of Exceptions to Confidentiality.
 One of ten adult resident service files did not contain documentation that an exit
interview was attempted or completed prior to the participant's departure from
shelter. (2nd consecutive year- repeat finding)
 One of ten adult resident service files contained notes that did not document services
provided.
 Two of ten adult resident service files contained service note corrections that were
 Two of ten adult outreach service files contained service note corrections that were
 Three of ten child resident service files contained service note corrections that were
 One of ten adult outreach service files contained unnecessary/inappropriate
documentation.
 Two of ten adult resident service files contained unnecessary/inappropriate notes.
 One of ten child resident service files contained unnecessary/inappropriate notes.
 Thirteen of fifteen hotline calls did not contain documentation of an assessment for
 Ten of fifteen hotline calls did not contain documentation of safety planning.
Corrective Action: Peace River Center for Personal Development, Inc. shall develop a
corrective action plan to ensure that service file requirements are completed and maintained
in accordance with Section 39.908, F.S., FCADV Program Standards and the FCADV
Contract.
Finding 4: Notification of Exceptions to Confidentiality
Section 39.908, Florida Statutes, requires that information about a client or the location
of a domestic violence center may be given by center staff or volunteers to law enforcement,
firefighting, medical, or other personnel in the following circumstances: (a) to medical
personnel in a medical emergency, (b) upon a court order based upon an application by a
law enforcement officer for a criminal arrest warrant which alleges that the individual
sought to be arrested is located at the domestic violence shelter, (c) upon a search warrant
that specifies the individual or object of the search and alleges that the individual or object
is located at the shelter, (d) to firefighting personnel in a fire emergency, (e) to any other
person necessary to maintain the safety and health standards in the domestic violence
shelter, (f) law enforcement when the information is directly related to a client's
commission of a crime or threat to commit a crime on the premises of the domestic violence
shelter, (g) reporting suspected abuse of a child or a vulnerable adult as required by law.

Page 10 of 12
A review of the Notification of Exceptions to Confidentiality revealed the following:
 The Notification of Exceptions to Confidentiality does not include law enforcement

when the information is directly related to a client's commission of a crime or threat
to commit a crime on the premises of the domestic violence shelter.
Corrective Action: Peace River Center for Personal Development, Inc. shall revise the
Notification of Exceptions to Confidentiality to meet the requirements of Section 39.908,
Florida Statutes. In addition, the Center shall provide direct-service staff training regarding
the revised Notification of Exceptions to Confidentiality.
In accordance with Chapter 65H-1.015(2)(j), F.A.C., Peace River Center for Personal
Development, Inc. shall ensure that each shelter facility has an annual sanitation
maintained in the Peace River Center for Personal Development, Inc. records and made
available for inspection upon request.
 The Sebring shelter facility had an annual sanitation inspection through its local
county health department; however, the inspection was not timely completed.
Finding 6: Staffing and Privilege
FCADV Program Standards require that prior to receiving calls, hotline staff will qualify
and register for privileged communications with FCADV, as required by 90.5036 F.S.
FCADV Program Standards further require that all domestic violence center employees
and volunteers having direct contact with participants and/or their related documents shall
complete 30 hours of initial domestic violence training and become registered for
privileged communications, as provided in Florida Statutes.
FCADV Training Guide requires that Core Competency training and Privilege
Registration must be completed within 90 days of initial employment (or direct-service
start date for volunteers) and before any unsupervised contact with participants.
Employees and volunteers must complete 24 hours of FCADV Competency-Based Core
Curriculum and 6 additional hours of specialized training (on-the-job orientation or
training of skills related to the performance of the individual's required duties).

Page 11 of 12
Documentation shall include FCADV certificates and/or FCADV privilege lists showing
the staff name as "active."
In accordance with the FCADV Contract, Peace River Center for Personal Development,
Inc.’s staff members or volunteers who supervise, coordinate, and/or provide direct
services to center participants shall successfully complete thirty (30) hours of specialized
training, and the Center must submit the privilege registration application to the FCADV,
within 90 days of employee’s initial employment or volunteer start date with the Provider.
A review of shelter documents revealed the following:
 Two advocates not listed on Peace River Center for Personal Development, Inc.’s
privilege list were unsupervised while providing services and answering hotline calls
in the Lakeland shelter.
corrective action plan to ensure that all of Peace River Center for Personal Development,
Inc.’s direct-service employees and volunteers have completed Core-Competency training
and are registered for privileged communication prior to working unsupervised with
participants and answering the hotline.
Peace River Center for Personal Development, Inc.’s Board Chair and Treasurer were
services, Peace River Center for Personal Development, Inc.’s budget and financial
of Peace River Center for Personal Development, Inc. The shelter facility was in good
condition at the time of the onsite monitoring visit.
necessitate corrective action. If there is a finding(s) of noncompliance, Peace River Center
for Personal Development, Inc. is required to submit a written response in the form of a
Monitoring Corrective Action Plan within 10 business days of receipt of the FCADV

Page 12 of 12
Safe Place and Rape Crisis Center, Inc.

Agency: Safe Place and Rape Crisis Center, Inc.
Onsite Dates Monitored: February 4, 2019 – February 8, 2019 (followed by a desk review
through March 1, 2019)
Review Period: December 1, 2017 – March 1, 2019
Release Date of Report: March 1, 2019

conducted the fiscal year 2018-2019 annual quality assurance monitoring of Safe Place and
Rape Crisis Center, Inc. on February 4, 2019 through February 8, 2019 with a continuation
of a desk review through March 1, 2019. The contracts and grants that were monitored
include:

30, 2018;
30, 2018;
September 30, 2019;
September 30, 2018;
2018 through September 30, 2019; and
2017 through September 30, 2018.

Page 2 of 8
the President/CEO and management staff. A formal exit conference was held on March 1,
2019.
The Program Monitor identified findings related to service file documentation.
II. INTRODUCTION
Safe Place and Rape Crisis Center, Inc. is a nonprofit organization headquartered in
Sarasota, Florida which provides DeSoto and Sarasota counties with the following services:
emergency shelter, 24-hour hotline, counseling, information and referral, case
Safe Place and Rape Crisis Center, Inc. was last monitored through an onsite review by
FCADV on November 14, 2017 through November 17, 2017. During that monitoring,
Safe Place and Rape Crisis Center, Inc. is a Florida Certified Domestic Violence Center
which is certified by the Florida Department of Children and Families (“The Department”).
The last certification review was completed on June 29, 2018 and Safe Place and Rape
Crisis Center, Inc. passed with no corrective action required. The effective dates of the
current certification are July 1, 2018 through June 30, 2019. Per Florida Administrative
Code, Chapter 65H-1.012, The Department will annually renew a center’s certification
upon the June 30 expiration date provided The Department has received a favorable
monitoring report from the Coalition.
The accounting firm of Bobbitt, Pittenger and Company, P.A. issued an unmodified,
independent audit report for the fiscal year ending June 30, 2018, with no findings noted.
A management letter was reviewed by FCADV.
The purpose of the review was to determine whether Safe Place and Rape Crisis Center,
Inc. has complied with the requirements of Chapter 65H-1, Florida Administrative Code
(F.A.C.); Sections 39.905 and 39.908, Florida Statutes; the terms and conditions of the

Page 3 of 8
to:

Page 4 of 8
 Reviewing Safe Place and Rape Crisis Center, Inc.’s contract files and discussing any
pertinent issues with the contract manager.


Page 5 of 8
FCADV Program Standards require that Safe Place and Rape Crisis Center, Inc. must
document attempts to provide an exit interview with each participant prior to their
departure from the domestic violence shelter.

groups not employed by Safe Place and Rape Crisis Center, Inc. shall not be initiated
without the participant's signed Release of Confidential Information Form. These contacts
shall also apply between centers. The Release of Confidential Information Form must
contain the following: participant's name, specific information to be released, to whom
information is to be given, specific expiration date for release of information, participant's
signature, and revocation statement. The FCADV Contract further requires that Safe
Place and Rape Crisis Center, Inc. shall use the FCADV's approved Release of
Confidential Information Form for the release of confidential participant information. If
Safe Place and Rape Crisis Center, Inc. prefers to use a substantially similar Release of
Confidential Information Form, the alternate form must be submitted to the FCADV
contract manager for approval prior to its use.
FCADV Program Standards require that Safe Place and Rape Crisis Center, Inc. shall
develop a written grievance procedure that is to be provided to each program participant
upon acceptance into the center and posted for outreach program participants or other
non-shelter participants.

Page 6 of 8
 One of ten adult resident service files did not contain a description of the abuser.
 Eight of ten adult resident service files did not contain documentation that an exit
interview was attempted or completed prior to the participant's departure from
shelter.
 Three of twelve adult outreach service files did not contain properly executed Release
of Confidential Information form(s).
 Four of ten child resident service files did not contain a signed consent for each
service provided.
 One of twelve adult outreach service files did not contain documentation that the
participant received a copy of the grievance procedure; and, the grievance procedure
was not posted for outreach program participants.
 One of ten adult resident service files contained service note corrections that were
 One of twelve adult outreach service files contained service note corrections that were
 One of ten adult resident service files contained unnecessary/inappropriate notes.
 One of twelve adult outreach service files contained unnecessary/inappropriate notes.
 Eight of fifteen hotline calls did not contain documentation of an assessment for
Corrective Action: Safe Place and Rape Crisis Center, Inc. shall develop a corrective
action plan to ensure that service file requirements are completed and maintained in
accordance with Section 39.908, F.S., FCADV Program Standards and the FCADV
Contract.
Safe Place and Rape Crisis Center, Inc.’s Board Chair and Treasurer were interviewed
during the onsite monitoring visit. The Board members responded to questions regarding,
but not limited to, Board training, policies, practices, survivor services, Safe Place and

Page 7 of 8
Rape Crisis Center, Inc.’s budget and financial viability, and revenue and resource-
generating efforts.
of Safe Place and Rape Crisis Center, Inc. The shelter facility was in good condition at the
time of the onsite monitoring visit.
necessitate corrective action. If there is a finding(s) of noncompliance, Safe Place and Rape
Crisis Center, Inc. is required to submit a written response in the form of a Monitoring
Action Plan.”

Page 8 of 8
Sunrise Domestic and Sexual Violence Center

Agency: Sunrise Domestic and Sexual Violence Center
Onsite Dates Monitored: March 11, 2019 – March 15, 2019 (followed by a desk review
through April 16, 2019)
Review Period: April 1, 2018 – April 16, 2019
Release Date of Report: April 16, 2019

NaTasha Bailey Evans, Contract Monitor
conducted the fiscal year 2018-2019 annual quality assurance monitoring of Sunrise
Domestic and Sexual Violence Center on March 11, 2019 through March 15, 2019 with a
continuation of a desk review through April 16, 2019. The contracts and grants that were
monitored include:

30, 2018;
30, 2018;
2019;
2018;
7. 19-2229-ES in the amount of $110,000.00, effective July 1, 2018 through June 30,
2019;
8. 18-2229-Enhancing Services in the amount of $67,572.56, effective October 1,
2017 through June 30, 2018;
September 30, 2019;
September 30, 2018;

Page 2 of 10
15. 19-2229-DELTA in the amount of $105,000.00, effective March 2, 2018 through
March 1, 2019.
April 16, 2019.
The Fiscal/Administrative Monitor identified findings related to personnel files, direct-

service volunteer files and financial documentation.
The Program Monitor identified findings related to service file documentation and the
shelter facility.
II. INTRODUCTION
Sunrise Domestic and Sexual Violence Center is a nonprofit organization headquartered in

Dade City, Florida which provides Pasco County with the following services: emergency
shelter, 24-hour hotline, counseling, information and referral, case management, child
assessments, community education, professional training, and outreach.
Sunrise Domestic and Sexual Violence Center was last monitored through an onsite review
by FCADV on March 26, 2018 through March 29, 2018. During that monitoring, FCADV
identified findings related to noncompliance with fiscal, administrative and program
functions. All issues were resolved.
Sunrise Domestic and Sexual Violence Center is a Florida Certified Domestic Violence
Center which is certified by the Florida Department of Children and Families (“The
Department”). The last certification review was completed on July 16, 2018 and Sunrise
Domestic and Sexual Violence Center passed with no corrective action required. The
effective dates of the current certification are July 13, 2018 through June 30, 2019. Per
Florida Administrative Code, Chapter 65H-1.012, The Department will annually renew a
center’s certification upon the June 30 expiration date provided The Department has
received a favorable monitoring report from the Coalition.

Page 3 of 10
The accounting firm of Baggett, Reutimann & Associates, CPAs, PA – John E. Henson,
CPA, PA issued an unmodified, independent audit report for the fiscal year ending June
30, 2017, with no findings noted.
The purpose of the review was to determine whether Sunrise Domestic and Sexual
Violence Center has complied with the requirements of Chapter 65H-1, Florida
information.


Page 4 of 10
to:

 Reviewing Sunrise Domestic and Sexual Violence Center’s contract files and


Page 5 of 10
 STOP Monitoring Tool
 DOJ/Other Monitoring Tool
Standards, Sunrise Domestic and Sexual Violence Center shall maintain a personnel file
for each employee performing services under this contract. The file shall include at a
minimum: service start date; employment application and/or résumé; reference checks;
signed and dated acknowledgment indicating that the employee read and understood
Sunrise Domestic and Sexual Violence Center’s policies and procedures relevant to their
position pursuant to Chapter 65H-1.013; signed and dated acknowledgement for receipt
of the employee handbook, which includes a confidentiality statement and drug-free
workplace statement (within 60 days of hire); a signed and dated position description,
which specifies the position responsibilities and qualifications; copies of signed and dated
annual performance evaluations; documentation of valid driver’s license for staff that
transport participants; proof of education and/or credentials as required; W-4
information; documentation of HIV/AIDS Universal Precautions training (within first year
of employment); documentation of advocate-victim privilege certification; documentation
of Anti-Bullying and Anti-Harassment training; “Serving our Customers who are Deaf or
Sunrise Domestic and Sexual Violence Center must also maintain, with respect to each
employee, either in the employee’s personnel file, or in a separate file: records of training
received for each employee, delineating the date and hours of training received; timesheets
and/or activity reports for employees; Department of Homeland Security Form I-9;
documentation of employment eligibility using E-verify; background screening, if

Page 6 of 10
required); and documentation of annual training on implementing the Sunrise Domestic
and Sexual Violence Center’s emergency management plan.
 One of sixteen personnel files did not contain completed employment application(s)
and/or résumé(s).

made, Sunrise Domestic and Sexual Violence Center shall, as applicable, demonstrate an
understanding of personnel file requirements, and shall develop a corrective action plan to
ensure that personnel file requirements are completed and maintained in accordance with
Standards, Sunrise Domestic and Sexual Violence Center shall maintain a personnel file
for each direct-service volunteer performing services under this contract. The file shall
include at a minimum: service start date; a signed and dated position description, which
specifies the position responsibilities and qualifications; documentation of advocate-victim
privilege certification; a signed and dated acknowledgment indicating that the volunteer
read and understood Sunrise Domestic and Sexual Violence Center’s policies and
procedures relevant to their volunteer duties pursuant to Chapter 65H-1.013; and a signed
and dated confidentiality statement and drug-free workplace statement (within 60 days of
service start date).
Sunrise Domestic and Sexual Violence Center must also maintain, with respect to each
direct-service volunteer, either in the volunteer’s personnel file, or in a separate file:
records of training received for each volunteer, delineating the date and hours of training
received, to include, but not be limited to, a customized, center specific data security
training, Emergency Management Plan training, Anti-Bullying and Anti-Harassment
training and 16 hours of in-service training; timesheets and/or activity reports for
volunteers; and documentation of Core Competency training within 90 days of the service
start date, if applicable.
 Four of five direct-service volunteer files did not contain signed and dated position
description(s).

Page 7 of 10
 Five of five direct-service volunteer files did not contain documentation of center-
service start date.
 Five of five direct-service volunteer files did not contain documentation of Anti-

made, Sunrise Domestic and Sexual Violence Center shall also, as applicable, demonstrate
an understanding of direct-service volunteer file requirements, and shall develop a
corrective action plan to ensure that direct-service volunteer file requirements are
completed and maintained in accordance with the FCADV Contract requirements and
invoice(s)/receipt(s); Sunrise Domestic and Sexual Violence Center records appropriate
coding on disbursements, which shall match coding in the accounting system; invoices are
timely paid by the due date stipulated on the invoice to avoid late fees; items purchased
are reasonable, allowable, and necessary expenditures; all invoices are defaced upon
payment; all disbursements have documented approval by the appropriate level of
management; dual signatures are on checks when required by policy or when the Sunrise
Domestic and Sexual Violence Center check signer is also the payee; disbursements are
allocated based on the FCADV- approved cost allocation plan for all funds administered
by FCADV; purchasing policies were followed, if applicable; voided checks shall be
clearly marked “VOID” and documented in the accounting system; and disbursements are
made in accordance with F.S. 112.061 (if the purchase relates to travel) for all funds
administered by FCADV.
Checks shall be released and cleared timely. Bank accounts shall be maintained properly,
so unnecessary fees are not incurred, such as overdraft or insufficient fund charges. Bank
reconciliations shall be performed monthly, reviewed and approved by the next level of
management or as designated in Sunrise Domestic and Sexual Violence Center’s relevant
policies.
 One of twenty operating checks included invoices that incurred late fees.
Corrective Action: Sunrise Domestic and Sexual Violence Center shall create a corrective
action plan to ensure that invoice and check requirements and documentation are
completed and maintained in accordance with the FCADV Fiscal Guide.

Page 8 of 10
 Two of ten adult outreach service files contained unnecessary/inappropriate notes.

 Five of ten child resident service files contained documents that identified other
 Four of fifteen hotline calls did not contain documentation of an assessment for
Corrective Action: Sunrise Domestic and Sexual Violence Center shall develop a
Contract.
 One shelter refrigerator handle was broken/missing.

 Cleaning products were not contained in an area inaccessible to children. (2nd
consecutive year- repeat finding)

Page 9 of 10
Corrective Action: Sunrise Domestic and Sexual Violence Center, shall develop a
corrective action plan to ensure that the facility is maintained according to the requirements
of Chapter 65H-1, F.A.C., FCADV Program Standards and Section 39.908, F.S.
Sunrise Domestic and Sexual Violence Center’s Board Chair was interviewed during the
onsite monitoring visit. The Board member responded to questions regarding, but not
limited to, Board training, policies, practices, survivor services, Sunrise Domestic and
Sexual Violence Center’s budget and financial viability, and revenue and resource-
generating efforts.
of Sunrise Domestic and Sexual Violence Center. The shelter facility was in good
condition at the time of the onsite monitoring visit with the exception of the specific
necessitate corrective action. If there is a finding(s) of noncompliance, Sunrise Domestic
and Sexual Violence Center is required to submit a written response in the form of a

Page 10 of 10
Quality Assurance Monitoring Report (Revised)
Religious Community Services, Inc. (The Haven of RCS)

Agency: Religious Community Services, Inc. (The Haven of RCS)
Onsite Dates Monitored: April 30, 2019 – May 3, 2019 (followed by a desk review through
June 19, 2019)
Review Period: April 1, 2018 – June 19, 2019
Release Date of Report: June 19, 2019
Monitoring Team: Ashly Delaney, Contract Monitor

Suncara S. Jackson, Contract Monitor
conducted the fiscal year 2018-2019 annual quality assurance monitoring of Religious
Community Services, Inc. (The Haven of RCS) on April 30, 2019 through May 3, 2019
with a continuation of a desk review through June 19, 2019. The contracts and grants that

30, 2018; and
$31,047.35, effective February 5, 2018 through May 31, 2018.
the Executive Director and management staff. A formal exit conference was held on June
4, 2019.

files, personnel files, staffing and contact change notification, inaccurate and late reports,
financial documentation, and audit requirements.
safety inspection requirement, annual sanitation inspection requirement, shelter facility,
empowerment-based advocacy, and civil rights compliance.

Page 2 of 16
II. INTRODUCTION
Religious Community Services, Inc. (The Haven of RCS) is a nonprofit organization

headquartered in Clearwater, Florida which provides Pinellas County with the following
services: emergency shelter, 24-hour hotline, counseling, information and referral, case
Religious Community Services, Inc. (The Haven of RCS) was last monitored through an
onsite review by FCADV on March 6, 2018 through March 9, 2018. During that
monitoring, FCADV identified findings related to noncompliance with fiscal,
administrative and program functions. Although all monitoring findings for fiscal year
2017-2018 were resolved, some issues continued to recur during the scope of the current
monitoring.
Religious Community Services, Inc. (The Haven of RCS) is a Florida Certified Domestic
(“The Department”). The last certification review was completed on August 17, 2018 and
Religious Community Services, Inc. (The Haven of RCS) passed with no corrective action
required. The effective dates of the current certification are August 1, 2018 through June
30, 2019. Per Florida Administrative Code, Chapter 65H-1.012, The Department will
annually renew a center’s certification upon the June 30 expiration date provided The
Department has received a favorable monitoring report from the Coalition.
The accounting firm of Carr Riggs & Ingram issued an unmodified, independent audit
report for the fiscal year ending September 30, 2017, with findings related to recognition
of irrevocable gifts. A management letter was reviewed by FCADV.
The purpose of the review was to determine whether Religious Community Services, Inc.
(The Haven of RCS) has complied with the requirements of Chapter 65H-1, Florida
information.


Page 3 of 16
to:

 Reviewing Religious Community Services, Inc. (The Haven of RCS)’s contract files
and discussing any pertinent issues with the contract manager.

Page 4 of 16

Standards, Religious Community Services, Inc. (The Haven of RCS) shall maintain a
personnel file for each direct-service volunteer performing services under this contract.
The file shall include at a minimum: service start date; a signed and dated position
description, which specifies the position responsibilities and qualifications; documentation
of advocate-victim privilege certification; a signed and dated acknowledgment indicating
that the volunteer read and understood Religious Community Services, Inc. (The Haven of
RCS)’s policies and procedures relevant to their volunteer duties pursuant to Chapter 65H-

Page 5 of 16
1.013; and a signed and dated confidentiality statement and drug-free workplace statement
(within 60 days of service start date).
Religious Community Services, Inc. (The Haven of RCS) must also maintain, with respect
to each direct-service volunteer, either in the volunteer’s personnel file, or in a separate
file: records of training received for each volunteer, delineating the date and hours of
training received, to include, but not be limited to, a customized, center specific data
security training, Emergency Management Plan training, Anti-Bullying and Anti-
Harassment training and 16 hours of in-service training; timesheets and/or activity reports
for volunteers; and documentation of Core Competency training within 90 days of the
service start date, if applicable.
 Seven of eleven direct-service volunteer files were not presented at the time of
monitoring.
 Four of four direct-service volunteer files did not contain signed and dated position
description(s).
 Four of four direct-service volunteer files did not contain signed and dated
acknowledgement(s) indicating that the volunteer(s) read and understood the center's
policies and procedures.
 One of four direct-service volunteer files did not contain a signed and dated
confidentiality statement.
 Four of four direct-service volunteer files did not contain a signed and dated drug-
free policy statement.
 Four of four direct-service volunteer files did not contain documentation of Core-
Competency training having been completed within 90 days of direct-service start
date.
 Three of four direct-service volunteer files did not contain documentation of center-
service start date. (*3rd consecutive year- repeat finding)
 Three of four direct-service volunteer files did not contain documentation of Anti-
direct-service start date. (*3rd consecutive year- repeat finding)
 Four of four direct-service volunteer files did not contain timesheets or activity logs.

made, Religious Community Services, Inc. (The Haven of RCS) shall also, as applicable,
demonstrate an understanding of direct-service volunteer file requirements, and shall
develop a corrective action plan to ensure that direct-service volunteer file requirements
are completed and maintained in accordance with the FCADV Contract requirements and

Page 6 of 16
Standards, Religious Community Services, Inc. (The Haven of RCS) shall maintain a
personnel file for each employee performing services under this contract. The file shall
include at a minimum: service start date; employment application and/or résumé;
reference checks; signed and dated acknowledgment indicating that the employee read and
understood Religious Community Services, Inc. (The Haven of RCS)’s policies and
procedures relevant to their position pursuant to Chapter 65H-1.013; signed and dated
acknowledgement for receipt of the employee handbook, which includes a confidentiality
statement and drug-free workplace statement (within 60 days of hire); a signed and dated
position description, which specifies the position responsibilities and qualifications; copies
of signed and dated annual performance evaluations; documentation of valid driver’s
license for staff that transport participants; proof of education and/or credentials as
required; W-4 information; documentation of HIV/AIDS Universal Precautions training
(within first year of employment); documentation of advocate-victim privilege
certification; documentation of Anti-Bullying and Anti-Harassment training; “Serving our
Customers who are Deaf or Hard-of-Hearing” certificates of completion; a signed and
dated “Support to the Deaf or Hard-of-Hearing Attestation Form”; and, if 15 or more
employees agency-wide, a signed and dated attestation that the employee is familiar with
the requirements of Section 504, the ADA, and CFOP 60-10, Chapter 4.
Religious Community Services, Inc. (The Haven of RCS) must also maintain, with respect
to each employee, either in the employee’s personnel file, or in a separate file: records of
required); and documentation of annual training on implementing the Religious
Community Services, Inc. (The Haven of RCS)’s emergency management plan.
 Five of twenty-three personnel files did not contain employment application(s) and/or
résumé(s). (2nd consecutive year- repeat finding)
 One of twenty-three personnel files contained current position description(s) that
were signed but not dated.
 One of twenty-three personnel files contained current position description(s) that
were not signed and dated.
 Fifteen of twenty-three personnel files did not contain current signed and dated
position description(s). (2nd consecutive year- repeat finding)

Page 7 of 16
 Two of twenty-three personnel files did not contain proof of education and/or
credentials, as required by the position description(s) on file.
 Eighteen of twenty-three personnel files did not contain reference checks.
 Eleven of twenty-three personnel files did not contain documentation of background
screening per agency policy.
 Twelve of twenty-three personnel files did not contain signed and dated
acknowledgment(s) indicating that the employee(s) read and understood the center's
policies and procedures relevant to their position. (2nd consecutive year- repeat
finding)
 Seventeen of twenty-three personnel files did not contain signed and dated
acknowledgement(s) for receipt of the employee handbook, which includes a
confidentiality statement.
 Six of twenty-three personnel files did not contain copies of valid driver's license(s),
as required by the position description on file.
 Twenty-three of twenty-three personnel files did not contain W-4 Form(s).
 Three of twenty-three personnel files did not contain Department of Homeland
Security Form I-9(s).
 Fourteen of twenty-three personnel files did not contain properly executed
Department of Homeland Security Form I-9(s). (*4th consecutive year- repeat
finding)
 Twenty of twenty-three personnel files did not contain documentation of completion
of employment eligiblity verification using E-verify. (2nd consecutive year- repeat
finding)
 One of twenty-three personnel files contained documentation of employment
eligibility verification using E-verify that was not completed timely.
 Five of twenty-three personnel files did not contain documentation of Core-
Competency training having been completed within 90 days of hire.
 Two of twenty-three personnel files did not contain documentation of advocate-
victim privilege registration having been completed within 30 days of hire.
 Nine of twenty-three personnel files did not contain attestation(s) regarding Section
504, the ADA, and CFOP 60-10, Chapter 4 that were signed and dated within 60 days
of hire. (*3rd consecutive year- repeat finding)
 Five of twenty-three personnel files did not contain "Support to the Deaf or Hard-of-
Hearing Attestation Form(s)" that were signed and dated within 60 days of hire. (*3rd
 Eleven of twenty-three personnel files did not contain Certificates of Completion for
the "Serving Our Customers who are Deaf or Hard-of-Hearing" online training that
were completed within 60 days of hire. (*3rd consecutive year- repeat finding)
 One of twenty-three personnel files did not contain documentation of annual
 Sixteen of twenty-three personnel files did not contain documentation of center-
specific Data Security training having been completed within 90 days of hire. (*3rd

Page 8 of 16
 Fourteen of twenty-three personnel files did not contain documentation of Anti-
Bullying and Anti-Harassment training having been completed within 60 days of hire.
(*3rd consecutive year- repeat finding)

made, Religious Community Services, Inc. (The Haven of RCS) shall, as applicable,
demonstrate an understanding of personnel file requirements, and shall develop a
corrective action plan to ensure that personnel file requirements are completed and
maintained in accordance with the FCADV Contract requirements and Chapter 65H-1.
F.A.C.
Finding 3: Staffing and Contact Change Notification
Pursuant to the FCADV Contract, Religious Community Services, Inc. (The Haven of RCS)
shall notify the FCADV in writing within five business days by the submission of an updated
Provider Contact Information Form, incorporated herein by reference when any position
listed on the Provider Contact Information Form is vacated or if the employee assigned to
the Executive Director or Fiscal Director position is unable to fulfill their duties and
responsibilities due to an extended absence of greater than two weeks. The notification
shall identify the person(s) assuming the responsibilities of the vacant position. When the
vacant position is filled, Religious Community Services, Inc. (The Haven of RCS) shall
notify the FCADV within five (5) business days of the change by the submission of an
updated Provider Contact Information Form. Documentation of credentials required by
Chapter 65H-1.013, F.A.C., shall be submitted along with any updated Provider Contact
Information Form. As required by Chapter 65H-1, F.A.C., the Executive Director,
Program Director, and Fiscal Director positions must be filled by three different people
each meeting the applicable requirements of Chapter 65H-1.013(8)(a), F.A.C.
Additionally, Religious Community Services, Inc. (The Haven of RCS) shall notify the
FCADV in writing within 48 hours when any contact information (i.e., email, address,
phone number, etc.) changes for any position listed on the Provider Contact Information
Form.
 Religious Community Services, Inc. (The Haven of RCS) did not provide written
notification to FCADV within five business days of the Emergency Coordinator
position being vacated and filled, which occurred in January 2019.
 Religious Community Services, Inc. (The Haven of RCS) did not provide
information for the Alternate Emergency Coordinator.
Corrective Action: Religious Community Services, Inc. (The Haven of RCS) shall
develop a corrective action plan to ensure that notification is provided to FCADV in
accordance with the FCADV Contract requirements and Chapter 65H-1, F.A.C.

Page 9 of 16
Finding 4: Inaccurate and Late Reports
Pursuant to the FCADV Contract, reports shall be received by the FCADV on or before
the dates listed in order to execute timely payment of this contract. Submission of reports
after the dates listed must be requested in writing with prior written approval by the
FCADV Contract Manager. Religious Community Services, Inc. (The Haven of RCS) shall
furnish other reports and information that the FCADV may require within the time
requested. Inaccurate or incomplete reports submitted by the due date will not be accepted.
The date on which the correct and/or complete report is received will be considered the
submission date.
A review of submitted invoices and reports revealed the following:
 Invoices and supporting documentation for the months of May 2018 through
February 2019 were not submitted timely.
Corrective Action: Religious Community Services, Inc. (The Haven of RCS) shall create
a corrective action plan to ensure that reports submitted are accurate, and shall also
demonstrate an understanding of the report deadlines in accordance with the FCADV
Contract requirements.
invoice(s)/receipt(s); Religious Community Services, Inc. (The Haven of RCS) records
appropriate coding on disbursements, which shall match coding in the accounting system;
invoices are timely paid by the due date stipulated on the invoice to avoid late fees; items
purchased are reasonable, allowable, and necessary expenditures; all invoices are defaced
upon payment; all disbursements have documented approval by the appropriate level of
management; dual signatures are on checks when required by policy or when the Religious
Community Services, Inc. (The Haven of RCS) check signer is also the payee;
disbursements are allocated based on the FCADV- approved cost allocation plan for all
funds administered by FCADV; purchasing policies were followed, if applicable; voided
checks shall be clearly marked “VOID” and documented in the accounting system; and
disbursements are made in accordance with F.S. 112.061 (if the purchase relates to travel)
for all funds administered by FCADV.
Travel expense reports shall include, at a minimum: expenses supported by original

receipts; a clearly-stated business purpose; pre-authorized conference expenses, if
applicable; a mileage sheet used to calculate and reimburse mileage expenses which
includes the purpose of travel and verification of the distance traveled.

Page 10 of 16
management or as designated in Religious Community Services, Inc. (The Haven of RCS)’s
relevant policies.
 Two of twenty-four operating checks did not contain appropriate coding on

supporting documentation.
 Three of twenty-four operating checks included invoices that incurred late fees.
 Three of twenty-four operating checks included supporting documentation that was
not defaced upon payment.
Corrective Action: Religious Community Services, Inc. (The Haven of RCS) shall, as
applicable, demonstrate an understanding of invoice and check requirements. Religious
Community Services, Inc. (The Haven of RCS) shall create a corrective action plan to
ensure that invoice and check requirements and documentation are completed and
maintained in accordance with the FCADV Fiscal Guide.
Finding 6: Audit Requirements
Pursuant to the FCADV Contract, a financial and compliance audit shall be provided to
the FCADV within 180 days after the end of Religious Community Services, Inc. (The
Haven of RCS)’s fiscal year or within 30 days of receipt of the audit report, whichever
occurs first. Religious Community Services, Inc. (The Haven of RCS) should include, when
available, correspondence from the auditor indicating the date the audit report package
was delivered to them, or when such correspondence is not available Religious Community
Services, Inc. (The Haven of RCS) must submit its own correspondence indicating the date
the audit report package was delivered by the auditor to Religious Community Services,
Inc. (The Haven of RCS).
A review of submitted reports revealed the following:
 Religious Community Services, Inc. (The Haven of RCS)’s audit report for fiscal
year ending September 30, 2018, which was due April 2019, was not submitted
timely.
demonstrate an understanding of the audit report deadlines, and shall ensure the audit report
is submitted timely in accordance with the FCADV Contract requirements.

Page 11 of 16
FCADV Program Standards require that Religious Community Services, Inc. (The Haven
of RCS) shall develop a written grievance procedure that is to be provided to each program
participant upon acceptance into the center and posted for outreach program participants
or other non-shelter participants.

groups not employed by Religious Community Services, Inc. (The Haven of RCS) shall not
be initiated without the participant's signed Release of Confidential Information Form.
These contacts shall also apply between centers. The Release of Confidential Information
Form must contain the following: participant's name, specific information to be released,
to whom information is to be given, specific expiration date for release of information,
participant's signature, and revocation statement.
one line through it, writing "error" and initialing this change; TANF Eligibility Forms
shall be kept in a separate confidential file; only necessary facts shall be recorded
regarding services delivered; notes shall not contain any diagnosis, clinical assessments,
or advocates' personal opinions, commentary or observations; notes on one survivor shall
not include other participants' names.
 Three of ten child resident service files did not contain documentation that age-
appropriate safety planning was conducted or offered.
 One of ten child resident service files did not contain a signed consent for each service
provided. (*4th consecutive year- repeat finding)

Page 12 of 16
 Six of ten child resident service files did not contain a signed consent for
assessment/services form or an indication of declination.
 Six of ten adult outreach service files did not contain documentation that the
participant received a copy of the grievance procedure; and, the grievance procedure
was not posted for outreach program participants.
 Five of ten adult resident service files contained service note corrections that were
 Two of ten child resident service files contained service note corrections that were
 Two of ten adult outreach service files contained unnecessary/inappropriate notes.
 One of ten adult resident service files contained unnecessary/inappropriate
documentation.
 One of ten adult outreach service files contained unnecessary/inappropriate
documentation.
 Two of fifteen hotline calls did not contain documentation of an assessment for
develop a corrective action plan to ensure that service file requirements are completed and
maintained in accordance with Section 39.908, F.S., FCADV Program Standards and the
FCADV Contract.
In accordance with Chapter 65H-1.015 (2)(i), F.A.C., Religious Community Services, Inc.
(The Haven of RCS), shall ensure that an annual fire safety inspection, which conforms to
fire safety standards as determined by each municipality, county, and special district with
fire safety responsibilities as defined in Section 633.025, F.S., is conducted for each shelter
facility. A current inspection shall be maintained in the Religious Community Services, Inc.
(The Haven of RCS) records and made available for inspection upon request.
department; however, the inspection was not timely completed. (2nd consecutive
develop a corrective action plan which demonstrates an understanding of the statutory

Page 13 of 16
requirement that an annual (within every 365 days) fire safety inspection that conforms to
the applicable fire safety standards must be conducted at each shelter facility according to
the requirements of Chapter 65H-1.015 (2)(i), F.A.C.
In accordance with Chapter 65H-1.015(2)(j), F.A.C., Religious Community Services, Inc.

(The Haven of RCS) shall ensure that each shelter facility has an annual sanitation
maintained in the Religious Community Services, Inc. (The Haven of RCS) records and
made available for inspection upon request.
 The shelter facility did not have an annual sanitation inspection through its local
county health department.
develop a corrective action plan which demonstrates an understanding of the statutory
requirement that an annual (within every 365 days) sanitation inspection must be conducted
at the shelter facility according to the requirements of Chapter 65H-1.015(2)(j), F.A.C.
 Areas of the shelter facility were in need of repair (three broken drawers in kitchen;
one of two microwaves not operable; handwashing sink in kitchen disconnected; hot
water in kitchen slow to heat up; bathtub drain plug missing from one family
bathroom; bathtub faucet leaking and drain not working properly in other family
bathroom).
 The shelter facility was not free of safety hazards (gaps in fence surrounding
participant parking area; fire escape plan missing from main participant entrance and
single’s hallway).
 Unrefrigerated fruit stored in a container on the countertop was bruised and did not
appear to be fresh.
Corrective Action: Religious Community Services, Inc. (The Haven of RCS), shall
develop a corrective action plan to ensure that the facility is maintained according to the
requirements of Chapter 65H-1, F.A.C., FCADV Program Standards and Section 39.908,
F.S.

Page 14 of 16
Finding 11: Empowerment-Based Advocacy
FCADV Program Standards require that all certified domestic violence centers provide
empowerment-based, survivor-directed services.
Interviews with shelter staff revealed the following:
 Bed checks are being conducted nightly.

 Participants are asked to be picked up/dropped off at alternate locations.
develop a corrective action plan to ensure that all of Religious Community Services, Inc.
(The Haven of RCS)’s practices are in alignment with the empowerment-based, survivor-
directed philosophy of the FCADV Program Standards.
Finding 12: Civil Rights Compliance
Pursuant to the FCADV Contract, of Religious Community Services, Inc. (The Haven of
RCS)’s Single-Point-of-Contact will ensure that the following three (3) notices are
conspicuously posted near where people enter or are admitted within the agent locations:
Interpreter Services for the Deaf and Hard of Hearing poster; DCF Non-Discrimination
poster; and Limited English Proficiency poster. Such notices must be posted immediately
by providers and subcontractors.
CFOP 60-10, Chapter 4 specifies that facility inspections will include verification that the
three required notices are posted in appropriate locations, are of appropriate size, and
that SPOC contact information is current on such notices.
 The required notices did not include the name and contact information of the Single
Point of Contact (SPOC).
develop a corrective action plan to ensure conspicuous notices are posted in compliance
with the FCADV Contract.
*NOTE: Religious Community Services, Inc. (The Haven of RCS) continues to have
repeat findings related to administrative and program operations.
Corrective Action for 3rd and 4th Consecutive Year Repeat Finding(s): In addition to
completing the corrective action steps to resolve the repeat finding(s), Religious
Community Services, Inc. (The Haven of RCS) shall create procedures for each repeat
finding to ensure the ongoing implementation of the corrective actions through an effective
quality assurance process. For each finding noted, the procedures shall identify: the
specific action steps to be taken, which staff are responsible for ensuring the completion of

Page 15 of 16
the action steps, how often a quality assurance review will be completed, and how the
completion of the action steps will be documented.
Religious Community Services, Inc. (The Haven of RCS)’s Board Chair and Vice Chair
were interviewed during the onsite monitoring visit. The Board members responded to
services, Religious Community Services, Inc. (The Haven of RCS)’s budget and financial
of Religious Community Services, Inc. (The Haven of RCS). The shelter facility was in
good condition at the time of the onsite monitoring visit with the exception of the specific
necessitate corrective action. If there is a finding(s) of noncompliance, Religious
Community Services, Inc. (The Haven of RCS) is required to submit a written response in
the form of a Monitoring Corrective Action Plan within 10 business days of receipt of the
FCADV Quality Assurance Monitoring Report. The format for the Monitoring Corrective
Action Plan will be provided by the FCADV. The completed Monitoring Corrective Action
Plan shall be submitted electronically to the FCADV via TrackIt in a file labeled
“Monitoring Corrective Action Plan.”

Page 16 of 16
The Salvation Army, A Georgia Corporation d/b/a The Salvation

Army of West Pasco

Agency: The Salvation Army, A Georgia Corporation d/b/a The Salvation

Army of West Pasco
Onsite Dates Monitored: August 21, 2018 – August 24, 2018 (followed by a desk review
through September 24, 2018)
Review Period: December 1, 2017 – September 24, 2018
Release Date of Report: September 25, 2018

conducted the fiscal year 2018-2019 annual quality assurance monitoring of The Salvation
Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco on August 21,
2018 through August 24, 2018 with a continuation of a desk review through September 24,
2018. The contracts and grants that were monitored include:

2. 18-2226-DVS-#2 in the amount of $399,090.72, effective July 1, 2017 through
June 30, 2018; and
3. 18-2226-CPI-GR in the amount of $8,207.75, effective July 1, 2017 through
December 31, 2017.
the Executive Director and management staff. A formal exit conference was held on
September 24, 2018.
The Fiscal/Administrative Monitor identified findings related to personnel files, financial

documentation, and position requirements.
The Program Monitor identified findings related to service file documentation, notification
of exceptions to confidentiality, annual sanitation inspection requirement, inconsistent
access to the hotline via TDD/TTY services, shelter facility, and empowerment-based
advocacy.
The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco
Page 2 of 13
II. INTRODUCTION
The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco is a
nonprofit organization headquartered in Hudson, Florida which provides Pasco County
with the following services: emergency shelter, 24-hour hotline, counseling, information
and referral, case management, child assessments, community education, professional
training, and outreach.
The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco was
last monitored through an onsite review by FCADV on November 13, 2017 through
November 17, 2017. During that monitoring, FCADV identified findings related to
noncompliance with fiscal, administrative and program functions. Although all monitoring
findings for fiscal year 2017-2018 were resolved, some issues continued to recur during
the scope of the current monitoring.
The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco is a
Florida Certified Domestic Violence Center which is certified by the Florida Department
of Children and Families (“The Department”). The last certification review was completed
on June 30, 2018 and The Salvation Army, A Georgia Corporation d/b/a The Salvation
Army of West Pasco passed with no corrective action required. The effective dates of the
current certification are July 1, 2018 through June 30, 2019. Per Florida Administrative
Code, Chapter 65H-1.012, The Department will annually renew a center’s certification
upon the June 30 expiration date provided The Department has received a favorable
monitoring report from the Coalition.
The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco did
not meet the threshold required for an audit to be completed.
The purpose of the review was to determine whether The Salvation Army, A Georgia
Corporation d/b/a The Salvation Army of West Pasco has complied with the requirements
of Chapter 65H-1, Florida Administrative Code (F.A.C.); Sections 39.905 and 39.908,
Florida Statutes; the terms and conditions of the aforementioned FCADV contracts; the
Department Certification Standards; the FCADV Fiscal Guide; the FCADV Contract
Monitoring Frequently Asked Questions (FAQs); and FCADV Program and
Administrative Standards. The review involved performing tests of compliance including
a review of policies and procedures, administrative records, invoices, financial reports,
program reports, and other required information.
Page 3 of 13
to:
Page 4 of 13
 Reviewing The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of
West Pasco’s contract files and discussing any pertinent issues with the contract
manager.

Standards, The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West
Pasco shall maintain a personnel file for each employee performing services under this
contract. The file shall include at a minimum: service start date; employment application
Page 5 of 13
and/or résumé; reference checks; signed and dated acknowledgment indicating that the
employee read and understood The Salvation Army, A Georgia Corporation d/b/a The
Salvation Army of West Pasco’s policies and procedures relevant to their position pursuant
to Chapter 65H-1.013; signed and dated acknowledgement for receipt of the employee
handbook, which includes a confidentiality statement and drug-free workplace statement
(within 60 days of hire); a signed and dated position description, which specifies the
position responsibilities and qualifications; copies of signed and dated annual
performance evaluations; documentation of valid driver’s license for staff that transport
participants; proof of education and/or credentials as required; W-4 information;
documentation of HIV/AIDS Universal Precautions training (within first year of
employment); documentation of advocate-victim privilege certification; documentation of
Anti-Bullying and Anti-Harassment training; “Serving our Customers who are Deaf or
The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco must
also maintain, with respect to each employee, either in the employee’s personnel file, or in
a separate file: records of training received for each employee, delineating the date and
hours of training received; timesheets and/or activity reports for employees; Department
of Homeland Security Form I-9; documentation of employment eligibility using E-verify;
background screening, if applicable; documentation of Core Competency training within
90 days of hire, if applicable; documentation of a customized, center-specific data security
training (within 90 days of hire); documentation of a signed DCF Security Agreement
Form CF 0114 (if required); documentation of the latest Departmental security awareness
training (if required); and documentation of annual training on implementing the The
Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco’s
emergency management plan.
 Two of nine personnel files did not contain properly executed Department of
Homeland Security Form I-9(s). (2nd consecutive year- repeat finding)
 One of nine personnel files did not contain annual signed and dated "Support to the
Deaf or Hard-of-Hearing Attestation Form(s)".
 One of nine personnel files did not contain documentation of annual Emergency
Management Plan training. (2nd consecutive year- repeat finding)
 One of nine personnel files did not contain documentation of annual center-specific
Data Security training. (2nd consecutive year- repeat finding)
 Six of nine personnel files did not contain documentation of center-specific Data
Security training having been completed within 90 days of hire.
 One of nine personnel files did not contain documentation of annual Anti-Bullying
and Anti-Harassment training. (*3rd consecutive year- repeat finding)
Page 6 of 13
 The personnel file for the designated Single-Point-of-Contact (SPOC) did not contain
annual signed and dated “Support to the Deaf or Hard-of-Hearing Attestation Form”
and Certificates of Completion for all four modules of the "Serving Our Customers
who are Deaf or Hard-of-Hearing" online training.

made, The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West
Pasco shall, as applicable, demonstrate an understanding of personnel file requirements,
and shall develop a corrective action plan to ensure that personnel file requirements are
completed and maintained in accordance with the FCADV Contract requirements and
Chapter 65H-1. F.A.C.
invoice(s)/receipt(s); The Salvation Army, A Georgia Corporation d/b/a The Salvation
Army of West Pasco records appropriate coding on disbursements, which shall match
coding in the accounting system; invoices are timely paid by the due date stipulated on the
invoice to avoid late fees; items purchased are reasonable, allowable, and necessary
expenditures; all invoices are defaced upon payment; all disbursements have documented
approval by the appropriate level of management; dual signatures are on checks when
required by policy or when the The Salvation Army, A Georgia Corporation d/b/a The
Salvation Army of West Pasco check signer is also the payee; disbursements are allocated
based on the FCADV- approved cost allocation plan for all funds administered by FCADV;
purchasing policies were followed, if applicable; voided checks shall be clearly marked
“VOID” and documented in the accounting system; and disbursements are made in
accordance with F.S. 112.061 (if the purchase relates to travel) for all funds administered
by FCADV.
 Four of twenty-two operating checks included invoices that were not paid timely by
the due date stipulated on the invoice. (*3rd consecutive year- repeat finding)
 Five of twenty-two operating checks included invoices that incurred late fees. (2nd

made, The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West
Pasco shall also, as applicable, demonstrate an understanding of invoice and check
requirements. The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of
West Pasco shall create a corrective action plan to ensure that invoice and check
requirements and documentation are completed and maintained in accordance with the
FCADV Fiscal Guide.
Page 7 of 13
Finding 3: Position Requirements
Pursuant to Rule 65H-1.013 (8)(a)(2), F.A.C., The Salvation Army, A Georgia Corporation
d/b/a The Salvation Army of West Pasco shall have one full-time advocate services
manager responsible for managing all advocacy, counseling, and volunteer services.
Qualifications include a Bachelor’s degree from an accredited college or university, or
four years of direct service experience in the field of domestic violence. The advocate
services manager must successfully complete 30 hours of domestic violence competency-
based core training within 90 days of the date of employment. Upon successful completion,
the advocate services manager must register according to Section 39.905, F.S., as someone
who may claim privilege under Section 90.5036, F.S.
 The Case Manager position does not meet the requirements as stated in Rule 65H-1-
1.013 (8)(a)(2), F.A.C., which requires “one full-time advocate services manager
responsible for managing all advocacy, counseling, and volunteer services.”
Corrective Action: Pursuant to Rule 65H-1.017(3), F.A.C., The Salvation Army, A

Georgia Corporation d/b/a The Salvation Army of West Pasco has ten business days from
the date of this report to submit a corrective action plan to FCADV, subject to FCADV
approval, addressing how it will bring itself into compliance with the minimum standards
for certification in Rule 65H-1.013(8)(a)(2). Failure by The Salvation Army, A Georgia
Corporation d/b/a The Salvation Army of West Pasco to timely complete a corrective active
plan as determined by FCADV will result in an unfavorable monitoring report that could
jeopardize its certification.
FCADV Program Standards require that The Salvation Army, A Georgia Corporation
d/b/a The Salvation Army of West Pasco shall open a file for every child receiving center
intervention services which includes an assessment of the child's basic needs. Basic needs
shall include, but not be limited to, immediate needs for food, clothing, shelter or health.
Additionally, for children residing in shelter, an assessment to assist in making appropriate
referrals to meet the child's individual needs shall be conducted within 72 hours of
admittance to the shelter. Services provided to children shall also include age-appropriate
safety planning with children.
Page 8 of 13
 Two of ten adult outreach service files did not contain a lethality assessment.
 Two of ten adult outreach service files did not contain documentation that
individualized safety planning was conducted.
 Two of ten adult outreach service files did not contain documentation of an
individualized service delivery plan.
 Five of ten adult outreach service files did not contain documentation that the
participant received a Notification of Exceptions to Confidentiality.
 One of ten child resident service files did not contain a basic needs assessment.
 One of fifteen hotline calls did not contain documentation of an assessment for danger
and lethality.
 Four of fifteen hotline calls did not contain documentation of safety planning.
Corrective Action: The Salvation Army, A Georgia Corporation d/b/a The Salvation
Army of West Pasco shall develop a corrective action plan to ensure that service file
requirements are completed and maintained in accordance with Section 39.908, F.S.,
FCADV Program Standards and the FCADV Contract.
Finding 5: Notification of Exceptions to Confidentiality
Section 39.908, Florida Statutes, requires that information about a client or the location
of a domestic violence center may be given by center staff or volunteers to law enforcement,
firefighting, medical, or other personnel in the following circumstances: (a) to medical
personnel in a medical emergency, (b) upon a court order based upon an application by a
law enforcement officer for a criminal arrest warrant which alleges that the individual
sought to be arrested is located at the domestic violence shelter, (c) upon a search warrant
that specifies the individual or object of the search and alleges that the individual or object
is located at the shelter, (d) to firefighting personnel in a fire emergency, (e) to any other
Page 9 of 13
person necessary to maintain the safety and health standards in the domestic violence
shelter, (f) law enforcement when the information is directly related to a client's
commission of a crime or threat to commit a crime on the premises of the domestic violence
shelter, (g) reporting suspected abuse of a child or a vulnerable adult as required by law.
A review of the Notification of Exceptions to Confidentiality revealed the following:
 The Notification of Exceptions to Confidentiality does not include law enforcement

when the information is directly related to a client's commission of a crime or threat
to commit a crime on the premises of the domestic violence shelter.
Army of West Pasco shall revise the Notification of Exceptions to Confidentiality to meet
the requirements of Section 39.908, Florida Statutes. In addition, the Center shall provide
direct-service staff training regarding the revised Notification of Exceptions to
Confidentiality.
In accordance with Chapter 65H-1.015(2)(j), F.A.C., The Salvation Army, A Georgia

Corporation d/b/a The Salvation Army of West Pasco shall ensure that each shelter facility
has an annual sanitation inspection through its local county health department. A current
inspection report shall be maintained in the The Salvation Army, A Georgia Corporation
d/b/a The Salvation Army of West Pasco records and made available for inspection upon
request.
Army of West Pasco shall develop a corrective action plan which demonstrates an
understanding of the statutory requirement that an annual (within every 365 days)
sanitation inspection must be conducted at the shelter facility according to the requirements
of Chapter 65H-1.015(2)(j), F.A.C.
Finding 7: Inconsistent Access to The Salvation Army, A Georgia Corporation d/b/a

The Salvation Army of West Pasco’s Hotline via TDD/TTY Services
In accordance with FCADV Program Standards; and Chapters 65H-1.014(5)(a) and 65H-
1.015(3), F.A.C., The Salvation Army, A Georgia Corporation d/b/a The Salvation Army
of West Pasco shall have a TDD/TTY/telephone relay service. The hotline must be
accessible via TDD/TTY/ telephone relay service.
Page 10 of 13
Random testing by FCADV of The Salvation Army, A Georgia Corporation d/b/a The
Salvation Army of West Pasco’s TDD/TTY hotline revealed the following:
 The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West
Pasco’s hotline was not consistently accessible via TDD/TTY services. (*3rd
Army of West Pasco, shall develop a corrective action plan to ensure that the hotline is
consistently accessible to callers via TDD/TTY/telephone relay services in accordance
with the FCADV Program Standards, and Chapters 65H-1.014(5)(a), and 65H-1.015 (3),
F.A.C.

FCADV Program Standards require that a copy of Section 39.908, Florida Statutes shall
be readily available to center staff/volunteers when confronted with confidentiality issues,
for immediate reference, especially when attorneys, law enforcement or process servers
are attempting to locate a victim of domestic violence.
 Areas of the shelter facility were in need of repair (torn screens on back porch,
overgrown grass around children’s play area, one of two dryers was un-operable,
Page 11 of 13
refrigerator needed cleaning, dead bug in the kitchen cabinet) . (2nd consecutive year-
repeat finding)
 The shelter facility was not free of safety hazards (broken table on back porch,
building materials accessible to children in the back yard, the gate to the maintenance
area was not closed and locked leaving it accessible to children, cleaning products
under bathroom sinks accessible to children). (2nd consecutive year- repeat finding)
Army of West Pasco, shall develop a corrective action plan to ensure that the facility is
maintained according to the requirements of Chapter 65H-1, F.A.C., FCADV Program
Standards and Section 39.908, F.S.
FCADV Program Standards require that The Salvation Army, A Georgia Corporation
d/b/a The Salvation Army of West Pasco shall provide all residents with food, clothing,
laundry detergent, hygiene items and access to telephones throughout their stay. These
basic needs shall be provided regardless of the participant's financial status or availability
of outside resources. Access to these basic needs shall not be limited to specific times and
shall be accessible without the assistance of staff. Shelters will provide, at a minimum,
food to include a variety within each of the following basic food groups: fruits, vegetables,
dairy, proteins, and starches.
FCADV Program Standards Frequently Asked Questions (FAQ) specify that food variety
for program participants would best be met by providing a combination of fresh, canned
and frozen items. FCADV considers basic hygiene items to be soap, shampoo, hair
conditioner, deodorant, toothpaste, toothbrushes, toilet paper, sanitary napkins/tampons
and disposable razors. For small children, additional basic hygiene items include diapers,
wipes, diaper cream and baby powder.
A review of shelter documents and observations by monitors revealed the following:
 Signage posted in the shelter facility contained disempowering language. (2nd

 The resident handbook contains disempowering language.
Army of West Pasco shall develop a corrective action plan to ensure that all of The
Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco’s
practices are in alignment with the empowerment-based, survivor-directed philosophy of
the FCADV Program Standards.
Page 12 of 13
*NOTE: The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of
West Pasco continues to have repeat findings related to fiscal, administrative and
program operations.
Corrective Action for 3rd Consecutive Year Repeat Finding(s): In addition to

completing the corrective action steps to resolve the repeat finding(s), The Salvation Army,
A Georgia Corporation d/b/a The Salvation Army of West Pasco shall create procedures
for each repeat finding to ensure the ongoing implementation of the corrective actions
through an effective quality assurance process. For each finding noted, the procedures
shall identify: the specific action steps to be taken, which staff are responsible for ensuring
the completion of the action steps, how often a quality assurance review will be completed,
and how the completion of the action steps will be documented.
The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco’s
Board Vice Chair and Advisory Board Member were interviewed during the onsite
monitoring visit. The Board members responded to questions regarding, but not limited
to, Board training, policies, practices, survivor services, The Salvation Army, A Georgia
Corporation d/b/a The Salvation Army of West Pasco’s budget and financial viability, and
revenue and resource-generating efforts.
of The Salvation Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco.
The shelter facility was in good condition at the time of the onsite monitoring visit with the
exception of the specific issue(s) identified in the "Shelter Facility" finding above.
necessitate corrective action. If there is a finding(s) of noncompliance, The Salvation
Army, A Georgia Corporation d/b/a The Salvation Army of West Pasco is required to
submit a written response in the form of a Monitoring Corrective Action Plan within 10
business days of receipt of the FCADV Quality Assurance Monitoring Report. The format
for the Monitoring Corrective Action Plan will be provided by the FCADV. The completed
Monitoring Corrective Action Plan shall be submitted electronically to the FCADV via
TrackIt in a file labeled “Monitoring Corrective Action Plan.”
Page 13 of 13
The Spring of Tampa Bay, Inc.

Agency: The Spring of Tampa Bay, Inc.
Onsite Dates Monitored: April 15, 2019 – April 18, 2019 (followed by a desk review through
May 20, 2019)
Review Period: February 1, 2018 – May 20, 2019
Release Date of Report: May 28, 2019

conducted the fiscal year 2018-2019 annual quality assurance monitoring of The Spring of
Tampa Bay, Inc. on April 15, 2019 through April 18, 2019 with a continuation of a desk
review through May 20, 2019. The contracts and grants that were monitored include:
1. Contract Nos. 19-2200-DVS in the amount of $1,385,182.36, effective July 1, 2018

2. 18-2200-DVS in the amount of $1,262,217.55, effective July 1, 2017 through June
30, 2018;
30, 2018;
September 30, 2019;
September 30, 2018;

Page 2 of 11
the President & CEO and management staff. A formal exit conference was held on May
20, 2019.
The Fiscal/Administrative Monitor identified findings related to personnel files and

financial documentation.
The Program Monitor identified findings related to service file documentation, shelter
facility, and civil rights compliance.
II. INTRODUCTION
The Spring of Tampa Bay, Inc. is a nonprofit organization headquartered in Tampa, Florida
which provides Hillsborough County with the following services: emergency shelter, 24-
hour hotline, counseling, information and referral, case management, child assessments,
community education, professional training, and outreach.
The Spring of Tampa Bay, Inc. was last monitored through an onsite review by FCADV
on January 8, 2018 through January 12, 2018. During that monitoring, FCADV identified
findings related to noncompliance with fiscal, administrative and program functions.
Although all monitoring findings for fiscal year 2017-2018 were resolved, some issues
continued to recur during the scope of the current monitoring.
The Spring of Tampa Bay, Inc. is a Florida Certified Domestic Violence Center which is
certified by the Florida Department of Children and Families (“The Department”). The last
certification review was completed on June 30, 2018 and The Spring of Tampa Bay, Inc.
passed with no corrective action required. The effective dates of the current certification
are July 1, 2018 through June 30, 2019. Per Florida Administrative Code, Chapter 65H-
1.012, The Department will annually renew a center’s certification upon the June 30
expiration date provided The Department has received a favorable monitoring report from
the Coalition.
The accounting firm of Rivero, Gordmier & Company, P.A., issued an unmodified,
independent audit report for the fiscal year ending June 30, 2018, with no findings noted.
The purpose of the review was to determine whether The Spring of Tampa Bay, Inc. has
complied with the requirements of Chapter 65H-1, Florida Administrative Code (F.A.C.);
Sections 39.905 and 39.908, Florida Statutes; the terms and conditions of the

Page 3 of 11


Page 4 of 11
to:

 Reviewing The Spring of Tampa Bay, Inc.’s contract files and discussing any pertinent
issues with the contract manager.


Page 5 of 11
Standards, The Spring of Tampa Bay, Inc. shall maintain a personnel file for each
employee performing services under this contract. The file shall include at a minimum:
service start date; employment application and/or résumé; reference checks; signed and
dated acknowledgment indicating that the employee read and understood The Spring of
Tampa Bay, Inc.’s policies and procedures relevant to their position pursuant to Chapter
65H-1.013; signed and dated acknowledgement for receipt of the employee handbook,
which includes a confidentiality statement and drug-free workplace statement (within 60
days of hire); a signed and dated position description, which specifies the position
responsibilities and qualifications; copies of signed and dated annual performance
evaluations; documentation of valid driver’s license for staff that transport participants;
proof of education and/or credentials as required; W-4 information; documentation of
HIV/AIDS Universal Precautions training (within first year of employment);
documentation of advocate-victim privilege certification; documentation of Anti-Bullying
and Anti-Harassment training; “Serving our Customers who are Deaf or Hard-of-
Hearing” certificates of completion; a signed and dated “Support to the Deaf or Hard-of-
Hearing Attestation Form”; and, if 15 or more employees agency-wide, a signed and dated
attestation that the employee is familiar with the requirements of Section 504, the ADA,
and CFOP 60-10, Chapter 4.
The Spring of Tampa Bay, Inc. must also maintain, with respect to each employee, either
in the employee’s personnel file, or in a separate file: records of training received for each
employee, delineating the date and hours of training received; timesheets and/or activity
reports for employees; Department of Homeland Security Form I-9; documentation of
employment eligibility using E-verify; background screening, if applicable; documentation
of Core Competency training within 90 days of hire, if applicable; documentation of a
customized, center-specific data security training (within 90 days of hire); documentation
of a signed DCF Security Agreement Form CF 0114 (if required); documentation of the
latest Departmental security awareness training (if required); and documentation of
annual training on implementing the The Spring of Tampa Bay, Inc.’s emergency
management plan.
 One of forty-two personnel files contained documentation of employment eligibility

verification using E-verify that was not completed timely. (*4th consecutive year-
repeat finding)
 One of forty-two personnel files did not contain attestation(s) regarding Section 504,
the ADA, and CFOP 60-10, Chapter 4 that were signed and dated within 60 days of
hire.

Page 6 of 11
Corrective Action: The Spring of Tampa Bay, Inc. shall, as applicable, demonstrate an
invoice(s)/receipt(s); The Spring of Tampa Bay, Inc. records appropriate coding on
disbursements, which shall match coding in the accounting system; invoices are timely
paid by the due date stipulated on the invoice to avoid late fees; items purchased are
reasonable, allowable, and necessary expenditures; all invoices are defaced upon
management; dual signatures are on checks when required by policy or when the The
Spring of Tampa Bay, Inc. check signer is also the payee; disbursements are allocated
based on the FCADV- approved cost allocation plan for all funds administered by FCADV;
purchasing policies were followed, if applicable; voided checks shall be clearly marked
“VOID” and documented in the accounting system; and disbursements are made in
accordance with F.S. 112.061 (if the purchase relates to travel) for all funds administered
by FCADV.

management or as designated in The Spring of Tampa Bay, Inc.’s relevant policies.
 Two of seven travel reimbursement checks did not contain appropriate mileage
documentation to verify distance traveled.
Corrective Action: The Spring of Tampa Bay, Inc. shall, as applicable, demonstrate an
understanding of invoice and check requirements. The Spring of Tampa Bay, Inc. shall
create a corrective action plan to ensure that invoice and check requirements and
documentation are completed and maintained in accordance with the FCADV Fiscal
Guide.

Page 7 of 11

groups not employed by The Spring of Tampa Bay, Inc. shall not be initiated without the
participant's signed Release of Confidential Information Form. These contacts shall also
apply between centers. The Release of Confidential Information Form must contain the
following: participant's name, specific information to be released, to whom information is
to be given, specific expiration date for release of information, participant's signature, and
revocation statement. The FCADV Contract further requires that The Spring of Tampa
Bay, Inc. shall use the FCADV's approved Release of Confidential Information Form for
the release of confidential participant information. If The Spring of Tampa Bay, Inc.
prefers to use a substantially similar Release of Confidential Information Form, the
alternate form must be submitted to the FCADV contract manager for approval prior to its
use.
FCADV Program Standards require that participants must be notified that an advocate
may release confidential information about participants without written consent in the
following circumstances: (a) reporting child abuse, (b) summoning emergency services,
such as medical personnel in a medical emergency; firefighting personnel in a fire
emergency; law enforcement with a search warrant or a criminal arrest warrant that
alleges the person or object being sought is located at the shelter; law enforcement when
the information being disclosed is directly related to a participant's commission of a crime
or threat to commit a crime on the premises of the shelter, (c) maintaining safety and health
standards of shelter facilities.
 Three of ten adult resident service files did not contain properly executed Release of

Page 8 of 11
 Two of ten adult outreach service files did not contain properly executed Release of
 Three of ten adult outreach service files did not contain appropriate Notification of
Exceptions to Confidentiality. (2nd consecutive year- repeat finding)
 Three of ten adult resident service files contained notes that did not document
services provided.
 Six of ten adult outreach service files contained notes that did not document services
provided.
 Three of ten child resident service files contained notes that did not document
services provided.
 Six of ten adult resident service files contained service note corrections that were not
completed by drawing a line through it, writing"error", and initialing the change.
 Two of ten adult resident service files contained unnecessary/inappropriate notes.
 One of ten child resident service files contained unnecessary/inappropriate notes.
 Five of fifteen hotline calls did not contain documentation of an assessment for
 Three of fifteen hotline calls did not contain documentation of safety planning.
Corrective Action: The Spring of Tampa Bay, Inc. shall develop a corrective action plan
to ensure that service file requirements are completed and maintained in accordance with
Section 39.908, F.S., FCADV Program Standards and the FCADV Contract.

 Corner trim on children’s playhouse was broken with exposed nail, creating a safety
hazard to children.

Page 9 of 11
 Participant refrigerator was in need of cleaning.

made, The Spring of Tampa Bay, Inc., shall develop a corrective action plan to ensure that
the facility is maintained according to the requirements of Chapter 65H-1, F.A.C., FCADV
Program Standards and Section 39.908, F.S.
Pursuant to the FCADV Contract, The Spring of Tampa Bay, Inc.’s Single-Point-of-
Contact will ensure that the following three (3) notices are conspicuously posted near
where people enter or are admitted within the agent locations: Interpreter Services for the
Deaf and Hard of Hearing poster; DCF Non-Discrimination poster; and Limited English
Proficiency poster. Such notices must be posted immediately by providers and
subcontractors.
A tour of the outreach facility revealed the following:
 The DCF Non-Discrimination and Limited English Proficiency notices were not posted
near where participants enter, or are admitted, into the shelter facility.
Corrective Action: The Spring of Tampa Bay, Inc. shall develop a corrective action plan
to ensure conspicuous notices are posted in compliance with the FCADV Contract.
*NOTE: The Spring of Tampa Bay, Inc. continues to have repeat findings related to
administrative operations.
Corrective Action for 4th Consecutive Year Repeat Finding(s): In addition to

completing the corrective action steps to resolve the repeat finding(s), The Spring of Tampa
Bay, Inc. shall create procedures for each repeat finding to ensure the ongoing
implementation of the corrective actions through an effective quality assurance process.
For each finding noted, the procedures shall identify: the specific action steps to be taken,
which staff are responsible for ensuring the completion of the action steps, how often a
quality assurance review will be completed, and how the completion of the action steps
will be documented.
The Spring of Tampa Bay, Inc.’s Board Chair and Treasurer were interviewed during the
onsite monitoring visit. The Board members responded to questions regarding, but not
limited to, Board training, policies, practices, survivor services, The Spring of Tampa Bay,
Inc.’s budget and financial viability, and revenue and resource-generating efforts.

Page 10 of 11
of The Spring of Tampa Bay, Inc. The shelter facility was in good condition at the time of
the onsite monitoring visit with the exception of the specific issue(s) identified in the
"Shelter Facility" finding above.
necessitate corrective action. If there is a finding(s) of noncompliance, The Spring of
Tampa Bay, Inc. is required to submit a written response in the form of a Monitoring
Action Plan.”

Page 11 of 11
Community Action Stops Abuse, Inc.

Agency: Community Action Stops Abuse, Inc.
Onsite Dates Monitored: February 26, 2019 – March 1, 2019 (followed by a desk review
through April 4, 2019)
Review Period: January 1, 2018 – April 4, 2019
Release Date of Report: April 5, 2019

Catherine Stratis, Contract Monitor
conducted the fiscal year 2018-2019 annual quality assurance monitoring of Community
Action Stops Abuse, Inc. on February 26, 2019 through March 1, 2019 with a continuation
of a desk review through April 4, 2019. The contracts and grants that were monitored
include:

30, 2018;
30, 2018;
April 4, 2019.

Page 2 of 14
files, personnel files, and financial documentation.
safety inspection requirement, annual sanitation inspection requirement, shelter facility,
civil rights compliance, and empowerment based advocacy.
II. INTRODUCTION
Community Action Stops Abuse, Inc. is a nonprofit organization headquartered in Saint

Petersburg, Florida which provides Pinellas County with the following services: emergency
Community Action Stops Abuse, Inc. was last monitored through an onsite review by
FCADV on December 5, 2017 through December 8, 2017. During that monitoring,
program functions. Although all monitoring findings for fiscal year 2017-2018 were
resolved, some issues continued to recur during the scope of the current monitoring.
Community Action Stops Abuse, Inc. is a Florida Certified Domestic Violence Center
which is certified by the Florida Department of Children and Families (“The Department”).
The last certification review was completed on June 28, 2018 and Community Action Stops
Abuse, Inc. passed with no corrective action required. The effective dates of the current
certification are July 1, 2018 through June 30, 2019. Per Florida Administrative Code,
Chapter 65H-1.012, The Department will annually renew a center’s certification upon the
June 30 expiration date provided The Department has received a favorable monitoring
report from the Coalition.
The accounting firm of Gregory, Sharer & Stuart, P.A. issued an unmodified, independent
audit report for the fiscal year ending June 30, 2018, with no findings noted.
The purpose of the review was to determine whether Community Action Stops Abuse, Inc.
has complied with the requirements of Chapter 65H-1, Florida Administrative Code
(F.A.C.); Sections 39.905 and 39.908, Florida Statutes; the terms and conditions of the

Page 3 of 14


Page 4 of 14
to:

 Reviewing Community Action Stops Abuse, Inc.’s contract files and discussing any
pertinent issues with the contract manager.


Page 5 of 14
Standards, Community Action Stops Abuse, Inc. shall maintain a personnel file for each
direct-service volunteer performing services under this contract. The file shall include at
a minimum: service start date; a signed and dated position description, which specifies the
position responsibilities and qualifications; documentation of advocate-victim privilege
certification; a signed and dated acknowledgment indicating that the volunteer read and
understood Community Action Stops Abuse, Inc.’s policies and procedures relevant to their
volunteer duties pursuant to Chapter 65H-1.013; and a signed and dated confidentiality
statement and drug-free workplace statement (within 60 days of service start date).
Community Action Stops Abuse, Inc. must also maintain, with respect to each direct-service
volunteer, either in the volunteer’s personnel file, or in a separate file: records of training
received for each volunteer, delineating the date and hours of training received, to include,
but not be limited to, a customized, center specific data security training, Emergency
Management Plan training, Anti-Bullying and Anti-Harassment training and 16 hours of
in-service training; timesheets and/or activity reports for volunteers; and documentation
of Core Competency training within 90 days of the service start date, if applicable.
 One of fourteen direct-service volunteer files did not contain documentation of

annual center-specific Data Security training. (2nd consecutive year- repeat finding)
 Nine of fourteen direct-service volunteer files did not contain documentation of
center-specific Data Security training having been completed within 90 days of
 One of fourteen direct-service volunteer files did not contain documentation of
annual Anti-Bullying and Anti-Harassment training. (2nd consecutive year- repeat
finding)
 Nine of fourteen direct-service volunteer files did not contain documentation of Anti-
direct-service start date. (*3rd consecutive year- repeat finding)

made, Community Action Stops Abuse, Inc. shall also, as applicable, demonstrate an
understanding of direct-service volunteer file requirements, and shall develop a corrective
action plan to ensure that direct-service volunteer file requirements are completed and
maintained in accordance with the FCADV Contract requirements and Chapter 65H-1,
F.A.C.

Page 6 of 14
Standards, Community Action Stops Abuse, Inc. shall maintain a personnel file for each
employee performing services under this contract. The file shall include at a minimum:
service start date; employment application and/or résumé; reference checks; signed and
dated acknowledgment indicating that the employee read and understood Community
Action Stops Abuse, Inc.’s policies and procedures relevant to their position pursuant to
Chapter 65H-1.013; signed and dated acknowledgement for receipt of the employee
handbook, which includes a confidentiality statement and drug-free workplace statement
(within 60 days of hire); a signed and dated position description, which specifies the
position responsibilities and qualifications; copies of signed and dated annual
performance evaluations; documentation of valid driver’s license for staff that transport
participants; proof of education and/or credentials as required; W-4 information;
documentation of HIV/AIDS Universal Precautions training (within first year of
employment); documentation of advocate-victim privilege certification; documentation of
Anti-Bullying and Anti-Harassment training; “Serving our Customers who are Deaf or
Community Action Stops Abuse, Inc. must also maintain, with respect to each employee,
either in the employee’s personnel file, or in a separate file: records of training received
for each employee, delineating the date and hours of training received; timesheets and/or
activity reports for employees; Department of Homeland Security Form I-9;
documentation of employment eligibility using E-verify; background screening, if
required); and documentation of annual training on implementing the Community Action
Stops Abuse, Inc.’s emergency management plan.
 One of thirty-eight personnel files did not contain copies of current signed and dated
annual performance evaluation(s).
 One of thirty-eight personnel files did not contain current signed and dated position
description(s).
 One of thirty-eight personnel files did not contain proof of education and/or
credentials, as required by the position description(s) on file.
 One of thirty-eight personnel files did not contain properly executed W-4 form(s).
 One of thirty-eight personnel files contained documentation of employment
eligibility verification using E-verify that was not completed timely.

Page 7 of 14
 One of thirty-eight personnel files did not contain documentation of advocate-victim
privilege registration having been completed within 30 days of hire.
 Five of thirty-eight personnel files did not contain Certificates of Completion for the
"Serving Our Customers who are Deaf or Hard-of-Hearing" online training that were
completed within 60 days of hire. (*4th consecutive year- repeat finding)
 Four of thirty-eight personnel files did not contain documentation of annual
 Twenty-two of thirty-eight personnel files did not contain documentation of center-
specific Data Security training having been completed within 90 days of hire.
 Twenty-five of thirty-eight personnel files did not contain documentation of Anti-
Bullying and Anti-Harassment training having been completed within 60 days of hire.
 Four of thirty-eight personnel files did not contain documentation of HIV/Universal
Precautions training having been completed within one year of hire.

made, Community Action Stops Abuse, Inc. shall, as applicable, demonstrate an
invoice(s)/receipt(s); Community Action Stops Abuse, Inc. records appropriate coding on
disbursements, which shall match coding in the accounting system; invoices are timely
paid by the due date stipulated on the invoice to avoid late fees; items purchased are
reasonable, allowable, and necessary expenditures; all invoices are defaced upon
management; dual signatures are on checks when required by policy or when the
Community Action Stops Abuse, Inc. check signer is also the payee; disbursements are
allocated based on the FCADV- approved cost allocation plan for all funds administered
by FCADV; purchasing policies were followed, if applicable; voided checks shall be
clearly marked “VOID” and documented in the accounting system; and disbursements are
made in accordance with F.S. 112.061 (if the purchase relates to travel) for all funds
administered by FCADV.


Page 8 of 14
management or as designated in Community Action Stops Abuse, Inc.’s relevant policies.
 Six of seven travel reimbursement checks included supporting documentation that

was not defaced upon payment.
Corrective Action: Community Action Stops Abuse, Inc. shall, as applicable, demonstrate
an understanding of invoice and check requirements. Community Action Stops Abuse, Inc.
shall create a corrective action plan to ensure that invoice and check requirements and
documentation are completed and maintained in accordance with the FCADV Fiscal
Guide.
child, the advocate needs to document this on the consent form.

groups not employed by Community Action Stops Abuse, Inc. shall not be initiated without
the participant's signed Release of Confidential Information Form. These contacts shall
also apply between centers. The Release of Confidential Information Form must contain
the following: participant's name, specific information to be released, to whom information
is to be given, specific expiration date for release of information, participant's signature,
and revocation statement.

Page 9 of 14
 Six of ten child resident service files did not contain a signed consent for each service
provided.
 Five of ten adult resident service files did not contain properly executed Release of
 Six of ten adult outreach service files contained service note corrections that were not
completed by drawing a line through it, writing"error", and initialing the change.
 Five of fifteen hotline calls did not contain documentation of an assessment for
Corrective Action: Community Action Stops Abuse, Inc. shall develop a corrective action
plan to ensure that service file requirements are completed and maintained in accordance
with Section 39.908, F.S., FCADV Program Standards and the FCADV Contract.
In accordance with Chapter 65H-1.015 (2)(i), F.A.C., Community Action Stops Abuse, Inc.,
shall ensure that an annual fire safety inspection, which conforms to fire safety standards
as determined by each municipality, county, and special district with fire safety
responsibilities as defined in Section 633.025, F.S., is conducted for each shelter facility.
A current inspection shall be maintained in the Community Action Stops Abuse, Inc.
records and made available for inspection upon request.
department; however, the inspection was not timely completed. (2nd consecutive
plan which demonstrates an understanding of the statutory requirement that an annual
(within every 365 days) fire safety inspection that conforms to the applicable fire safety
standards must be conducted at each shelter facility according to the requirements of
Chapter 65H-1.015 (2)(i), F.A.C.
In accordance with Chapter 65H-1.015(2)(j), F.A.C., Community Action Stops Abuse, Inc.
shall ensure that each shelter facility has an annual sanitation inspection through its local
county health department. A current inspection report shall be maintained in the

Page 10 of 14
Community Action Stops Abuse, Inc. records and made available for inspection upon
request.
department; however, the inspection was not timely completed. (*3rd consecutive
plan which demonstrates an understanding of the statutory requirement that an annual
(within every 365 days) sanitation inspection must be conducted at the shelter facility
according to the requirements of Chapter 65H-1.015(2)(j), F.A.C.

and shall be routinely checked for safety.
 Areas of the shelter facility were in need of cleaning, maintenance and repair (broken
exit door near living room; Kitchen B refrigerators needed cleaning; community
restroom(s) near lobby needed cleaning; cigarette butts on the ground in children’s
play area).
 The shelter facility was not free of safety hazards (cleaning products and bug traps in
kitchen, and laundry detergent in Welcome Center not contained in areas inaccessible
to children; participant freezer shelf removed and placed on dining table accessible
to children; warped picnic table outside in children’s play area; moldy bread available
for participants in Kitchen B).
 No plates or knives were available for participant use.
 Emergency telephone numbers were not posted by the telephones designated for
participant use.

Page 11 of 14
 The shelter’s cellular telephone was not charged and available for use in the event of
power and telephone line outages.
Corrective Action: Community Action Stops Abuse, Inc., shall develop a corrective
action plan to ensure that the facility is maintained according to the requirements of
Chapter 65H-1, F.A.C., FCADV Program Standards and Section 39.908, F.S.
Pursuant to the FCADV Contract, Community Action Stops Abuse, Inc. Single-Point-of-
Contact will ensure that the following three (3) notices are conspicuously posted near
where people enter or are admitted within the agent locations: Interpreter Services for the
Deaf and Hard of Hearing poster; DCF Non-Discrimination poster; and Limited English
Proficiency poster. Such notices must be posted immediately by providers and
subcontractors.
 The DCF Interpreter Services for the Deaf and Hard of Hearing, DCF Non-
Discrimination and Limited English Proficiency notices were not posted near where
participants enter, or are admitted, into the shelter location.
plan to ensure conspicuous notices are posted in compliance with the FCADV Contract.
FCADV Program Standards state that participation in support services shall be voluntary
and no punitive action shall be taken against those who do not participate.
FCADV Program Standards require that Community Action Stops Abuse, Inc. shall
provide all residents with food, clothing, laundry detergent, hygiene items and access to
telephones throughout their stay. These basic needs shall be provided regardless of the
participant's financial status or availability of outside resources. Access to these basic
needs shall not be limited to specific times and shall be accessible without the assistance
of staff. Shelters will provide, at a minimum, food to include a variety within each of the
following basic food groups: fruits, vegetables, dairy, proteins, and starches.
A review of shelter documents, and a tour of the shelter facility revealed the following:
 The Mental Health and Substance Use Advocacy form contains disempowering
language.

Page 12 of 14
 An advocate schedule posted in the shelter stated that participants are required to
meet with case managers at least twice per week.
 The shelter facility has inadequate kitchen facilities for 100+ residents, absent a plan
to prepare meals three times per day from Kitchen A.
 Community restrooms on the first floor remain locked unless a participant requests
to use the facilities.
plan to ensure that all of Community Action Stops Abuse, Inc.’s practices are in alignment
with the empowerment-based, survivor-directed philosophy of the FCADV Program
Standards.
*NOTE: Community Action Stops Abuse, Inc. continues to have repeat findings
related to administrative and program operations.
Corrective Action for 3rd and 4th Consecutive Year Repeat Finding(s): In addition to
completing the corrective action steps to resolve the repeat finding(s), Community Action
Stops Abuse, Inc. shall create procedures for each repeat finding to ensure the ongoing
implementation of the corrective actions through an effective quality assurance process.
For each finding noted, the procedures shall identify: the specific action steps to be taken,
which staff are responsible for ensuring the completion of the action steps, how often a
quality assurance review will be completed, and how the completion of the action steps
will be documented.
Community Action Stops Abuse, Inc.’s Board Chair and Treasurer were interviewed
during the onsite monitoring visit. The Board members responded to questions regarding,
but not limited to, Board training, policies, practices, survivor services, Community Action
Stops Abuse, Inc.’s budget and financial viability, and revenue and resource-generating
efforts.
of Community Action Stops Abuse, Inc. The shelter facility was in good condition at the
time of the onsite monitoring visit with the exception of the specific issue(s) identified in
the "Shelter Facility" finding above.
necessitate corrective action. If there is a finding(s) of noncompliance, Community Action
Stops Abuse, Inc. is required to submit a written response in the form of a Monitoring

Page 13 of 14
Action Plan.”

Page 14 of 14
Citrus County Abuse Shelter Association, Inc.

Agency: Citrus County Abuse Shelter Association, Inc.
Onsite Dates Monitored: October 9, 2018 – October 12, 2018 (followed by a desk review
through November 13, 2018)
Review Period: December 1, 2017 – November 13, 2018
Release Date of Report: November 14, 2018

Ashly Delaney, Contract Monitor
conducted the fiscal year 2018-2019 annual quality assurance monitoring of Citrus County
Abuse Shelter Association, Inc. on October 9, 2018 through October 12, 2018 with a
continuation of a desk review through November 13, 2018. The contracts and grants that

30, 2018;
30, 2018;
September 30, 2018;
September 30, 2019;

Page 2 of 8
November 13, 2018.
The Fiscal/Administrative Monitor identified findings related to inaccurate and late

reports.
The Program Monitors identified findings related to service file documentation, annual fire
safety inspection requirement, and annual sanitation inspection requirement.
II. INTRODUCTION
Citrus County Abuse Shelter Association, Inc. is a nonprofit organization headquartered in

Inverness, Florida which provides Citrus County with the following services: emergency
Citrus County Abuse Shelter Association, Inc. was last monitored through an onsite review
by FCADV on November 28, 2017 through October 1, 2017. During that monitoring,
Citrus County Abuse Shelter Association, Inc. is a Florida Certified Domestic Violence
Center which is certified by the Florida Department of Children and Families (“The
Department”). The last certification review was completed on June 28, 2018 and Citrus
County Abuse Shelter Association, Inc. passed with no corrective action required. The
effective dates of the current certification are July 1, 2018 through June 30, 2019. Per
Florida Administrative Code, Chapter 65H-1.012, The Department will annually renew a
center’s certification upon the June 30 expiration date provided The Department has
received a favorable monitoring report from the Coalition.
The accounting firm of Wardlow & Cash, P.A. issued an unmodified, independent audit
report for the fiscal year ending June 30, 2017, with no findings noted. A management letter
was reviewed by FCADV.
The purpose of the review was to determine whether Citrus County Abuse Shelter
Association, Inc. has complied with the requirements of Chapter 65H-1, Florida
information.

Page 3 of 8


Page 4 of 8
to:

 Reviewing Citrus County Abuse Shelter Association, Inc.’s contract files and


Page 5 of 8
Finding 1: Inaccurate and Late Reports
Pursuant to the FCADV Contract, reports shall be received by the FCADV on or before
the dates listed in order to execute timely payment of this contract. Submission of reports
after the dates listed must be requested in writing with prior written approval by the
FCADV Contract Manager. Citrus County Abuse Shelter Association, Inc. shall furnish
other reports and information that the FCADV may require within the time requested.
Inaccurate or incomplete reports submitted by the due date will not be accepted. The date
on which the correct and/or complete report is received will be considered the submission
date.
A review of submitted invoices and reports revealed the following:
 The Auxiliary Aid Service Record Monthly Summary (HHS) Report for the months
of April, June and July 2018 were not submitted timely.
 The Auxiliary Aid Service Record Monthly Summary (HHS) Report submitted for
the month of September 2018 was inaccurate.
Corrective Action: Citrus County Abuse Shelter Association, Inc. shall create a corrective
action plan to ensure that reports submitted are accurate, and shall also demonstrate an
understanding of the report deadlines in accordance with the FCADV Contract
requirements.

Page 6 of 8
 One of ten child resident service files did not contain documentation that a child
assessment was conducted or offered.
 Nine of ten child resident service files did not contain a signed consent for each
service provided.
 Seven of ten adult resident service files contained unnecessary/inappropriate notes.
 Three of ten adult outreach service files contained unnecessary/inappropriate notes.
 Four of ten adult resident service files contained notes that were not entered in
chronological order.
 Four of ten adult resident service files contained service note corrections that were
Corrective Action: Citrus County Abuse Shelter Association, Inc. shall develop a
Contract.
In accordance with Chapter 65H-1.015 (2)(i), F.A.C., Citrus County Abuse Shelter
Association, Inc., shall ensure that an annual fire safety inspection, which conforms to fire
safety standards as determined by each municipality, county, and special district with fire
safety responsibilities as defined in Section 633.025, F.S., is conducted for each shelter
facility. A current inspection shall be maintained in the Citrus County Abuse Shelter
Association, Inc. records and made available for inspection upon request.
that an annual (within every 365 days) fire safety inspection that conforms to the applicable
fire safety standards must be conducted at each shelter facility according to the
requirements of Chapter 65H-1.015 (2)(i), F.A.C.

Page 7 of 8
In accordance with Chapter 65H-1.015(2)(j), F.A.C., Citrus County Abuse Shelter

Association, Inc. shall ensure that each shelter facility has an annual sanitation inspection
through its local county health department. A current inspection report shall be maintained
in the Citrus County Abuse Shelter Association, Inc. records and made available for
inspection upon request.
Citrus County Abuse Shelter Association, Inc.’s Board President and Treasurer were
services, Citrus County Abuse Shelter Association, Inc.’s budget and financial viability,
and revenue and resource-generating efforts.
of Citrus County Abuse Shelter Association, Inc. The shelter facility was in good condition
at the time of the onsite monitoring visit.
necessitate corrective action. If there is a finding(s) of noncompliance, Citrus County
Abuse Shelter Association, Inc. is required to submit a written response in the form of a

Page 8 of 8

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Quality Assurance Monitoring Report

Salvare, Inc. d/b/a Dawn Center of Hernando County

Fiscal Year 2018-2019

Agency: Salvare, Inc. d/b/a Dawn Center of Hernando County

Review Period: November 1, 2017 – October 8, 2018

Release Date of Report: October 8, 2018

Monitoring Team: Suncara S. Jackson, Contract Monitor

1. Contract Nos. 19-2236-DVS in the amount of $343,701.58, effective July 1, 2018

Salvare, Inc. d/b/a Dawn Center of Hernando County

Salvare, Inc. d/b/a Dawn Center of Hernando County is a nonprofit organization

III. PURPOSE AND SCOPE

Salvare, Inc. d/b/a Dawn Center of Hernando County

The FCADV contract monitors conduct continuous compliance monitoring on an annual

IV. MONITORING METHODOLOGY

Salvare, Inc. d/b/a Dawn Center of Hernando County

 Evaluating laws, regulations, and applicable operating procedures.

 Fiscal/ Administrative Monitoring Tool

Salvare, Inc. d/b/a Dawn Center of Hernando County

Finding 1: Personnel Files

A review of personnel files revealed the following:

Salvare, Inc. d/b/a Dawn Center of Hernando County

Corrective Action: In addition to providing documentation to verify that corrections were

Finding 2: Financial Documentation

A review of invoices and financial records revealed the following:

Salvare, Inc. d/b/a Dawn Center of Hernando County

Finding 3: Participant and/or Emergency Shelter Location Identifying Information

A review of invoices and financial records revealed the following:

Finding 4: Service File Documentation

Salvare, Inc. d/b/a Dawn Center of Hernando County

Salvare, Inc. d/b/a Dawn Center of Hernando County

Finding 5: Annual Fire Safety Inspection Requirement

A review of shelter facility documents revealed the following:

Salvare, Inc. d/b/a Dawn Center of Hernando County

A review of shelter facility documents revealed the following:

Finding 7: Shelter Facility

In accordance with Chapter 65H-1015(2)(e), F.A.C., if an outside play area is made

Salvare, Inc. d/b/a Dawn Center of Hernando County

A tour of the shelter facility revealed the following:

VI. BOARD MEMBER INTERVIEWS

VII. SHELTER FACILITY

VIII. CORRECTIVE ACTION PLAN INSTRUCTIONS

Salvare, Inc. d/b/a Dawn Center of Hernando County

Salvare, Inc. d/b/a Dawn Center of Hernando County

HOPE Family Services, Inc.

Fiscal Year 2018-2019

Agency: HOPE Family Services, Inc.

Review Period: September 1, 2017 – March 7, 2019

Release Date of Report: March 8, 2019

Monitoring Team: Catherine Stratis, Contract Monitor

1. Contract Nos. 19-2213-DVS in the amount of $542,854.31, effective July 1, 2018

HOPE Family Services, Inc.

The Fiscal/Administrative Monitor identified findings related to personnel file

The Program Monitor identified findings related to service file documentation.

HOPE Family Services, Inc. is a nonprofit organization headquartered in Bradenton,

HOPE Family Services, Inc.

The FCADV contract monitors conduct continuous compliance monitoring on an annual

HOPE Family Services, Inc.

 Evaluating laws, regulations, and applicable operating procedures.

 Fiscal/ Administrative Monitoring Tool

HOPE Family Services, Inc.

V. FINDINGS AND CORRECTIVE ACTIONS

Finding 1: Personnel Files

A review of personnel files revealed the following: