EIN: 741400228
UEI: CTY3AC11HPE5
Data as of August 22, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on October 6, 2020. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by April 6, 2021 (1965 days ago).
What is a management decision? →Closeout Documents were completed and signed by the Executive Director on October 24, 2019 and program amount expended included only collections rather than billings. Cause: The RCSETX personnel responsible for preparation and submission of the Closeout Report inadvertently reported program eligible reimbursements as units of service collected rather than units of service provided and billed. Effect: Lack of accurate filing of required Closeout Documents is a noncompliance issue that does not negatively impact our opinion on compliance, but which has caused the auditee to lose the opportunity to collect, on a timely basis, receivables related to the realignment of funds within the program discussed in Finding 2019-001. Additionally, correction of these reporting issues required significant remedial action on the part of RCSETX personnel. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-002 to include quarterly and annual reporting requirements. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2019-003 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No. 2016-048550-003, Treatment Adult Services (TRA) Compliance ? Reporting Criteria: Financial Status Report (Form 269A) quarterly filing requirements were waived for the fiscal year ended August 31, 2019, however Closeout Documents were due 45 days after the Program Attachment end date and should have reported reimbursement reports based on units of service provided and billed. Condition: Closeout Documents were completed and signed by the Executive Director on October 24, 2019 and program amount expended included only collections rather than billings. Cause: The RCSETX personnel responsible for preparation and submission of the Closeout Report inadvertently reported program eligible reimbursements as units of service collected rather than units of service provided and billed. Effect: Lack of accurate filing of required Closeout Documents is a noncompliance issue that does not negatively impact our opinion on compliance, but which has caused the auditee to lose the opportunity to collect, on a timely basis, receivables related to the realignment of funds within the program discussed in Finding 2019-001. Additionally, correction of these reporting issues required significant remedial action on the part of RCSETX personnel. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-002 to include quarterly and annual reporting requirements. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2019-003/004/005 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Compliance ? Reporting Corrective Action Plan: Kathy Heidling, Billing Coordinator, has been trained as a backup for this quarterly task and will be available when Kristi Premeaux, Finance Director, is not available to complete said task. The Quality Management Committee referenced in 2019-001 and 2019-002 will review these reports contemporaneously. Completion Date: February 20, 2020 Responsible Party: Thomas Aardahl, Executive Director
2018-003
Financial Status Reports were not filed timely. Cause: The individual charged with responsibility for timely preparation and filing of the quarterly financial status reports had not recovered from the additional responsibilities and remedial efforts that were the direct result of the aftermath of Tropical Storm Harvey. Effect: Lack of timely filing of required Financial Status Reports is a noncompliance issue that does not negatively impact our opinion on compliance, but which may cause the auditee to take remedial action subsequent to the period under audit. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-002 to include quarterly and annual reporting requirements. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2019-004 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No. 2016-047896-003, Community Coalition Partnerships (CCP) Compliance ? Reporting Criteria: Financial Status Reports (Form 269A) are due quarterly, last business day of the month following end of each quarter of the Program and Close Out Documents are due 45 days after the Program Attachment end date. Condition: Financial Status Reports were not filed timely. Cause: The individual charged with responsibility for timely preparation and filing of the quarterly financial status reports had not recovered from the additional responsibilities and remedial efforts that were the direct result of the aftermath of Tropical Storm Harvey. Effect: Lack of timely filing of required Financial Status Reports is a noncompliance issue that does not negatively impact our opinion on compliance, but which may cause the auditee to take remedial action subsequent to the period under audit. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-002 to include quarterly and annual reporting requirements. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2019-003/004/005 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Compliance ? Reporting Corrective Action Plan: Kathy Heidling, Billing Coordinator, has been trained as a backup for this quarterly task and will be available when Kristi Premeaux, Finance Director, is not available to complete said task. The Quality Management Committee referenced in 2019-001 and 2019-002 will review these reports contemporaneously. Completion Date: February 20, 2020 Responsible Party: Thomas Aardahl, Executive Director
2018-004
Financial Status Reports were not filed timely. Cause: The individual charged with responsibility for timely preparation and filing of the quarterly financial status reports had not recovered from the additional responsibilities and remedial efforts that were the direct result of the aftermath of Tropical Storm Harvey. Effect: Lack of timely filing of required Financial Status Reports is a noncompliance issue that does not negatively impact our opinion on compliance, but which may cause the auditee to take remedial action subsequent to the period under audit. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-002 to include quarterly and annual reporting requirements. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2019-005 ? Substance Abuse and Mental Health Services Administration (CFDA 93.788) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No: HHS000128700011, Texas? Targeted Opioid Response (TTOR) Compliance ? Reporting Criteria: Financial Status Reports (Form 269A) are due quarterly, last business day of the month following end of each quarter of the Program and Close Out Documents are due 45 days after the Program Attachment end date. Condition: Financial Status Reports were not filed timely. Cause: The individual charged with responsibility for timely preparation and filing of the quarterly financial status reports had not recovered from the additional responsibilities and remedial efforts that were the direct result of the aftermath of Tropical Storm Harvey. Effect: Lack of timely filing of required Financial Status Reports is a noncompliance issue that does not negatively impact our opinion on compliance, but which may cause the auditee to take remedial action subsequent to the period under audit. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-002 to include quarterly and annual reporting requirements. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2019-003/004/005 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Compliance ? Reporting Corrective Action Plan: Kathy Heidling, Billing Coordinator, has been trained as a backup for this quarterly task and will be available when Kristi Premeaux, Finance Director, is not available to complete said task. The Quality Management Committee referenced in 2019-001 and 2019-002 will review these reports contemporaneously. Completion Date: February 20, 2020 Responsible Party: Thomas Aardahl, Executive Director
2019-006 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No. 2016-048550-003, Treatment Adult Services (TRA). Compliance ? Special Testing Criteria: TRA ? Residential Program client files should contain progress notes prepared by a responsible party. Condition & Context: Of 40 client files reviewed, 1 did not contain progress notes prepared by a responsible party. Cause: The individual responsible for the preparation and inclusion of progress note in the client file inadvertently failed to do so. Effect: Lack of progress notes prevents timely third-party review of client status. Recommendation: Management should emphasize the need to complete and document each program requirement. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2019-006 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No. 2016-048550-003, Treatment Adult Services (TRA). Compliance ? Special Testing Criteria: TRA ? Residential Program client files should contain progress notes prepared by a responsible party. Condition & Context: Of 40 client files reviewed, 1 did not contain progress notes prepared by a responsible party. Cause: The individual responsible for the preparation and inclusion of progress note in the client file inadvertently failed to do so. Effect: Lack of progress notes prevents timely third-party review of client status. Recommendation: Management should emphasize the need to complete and document each program requirement. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2019-006/007 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Compliance ? Special Testing Corrective Action Plan: We have updated our Quality Management Plan and established the Quality Management Committee, referenced in 2019-001 and 2019-002, that is responsible for coordinating monthly auditing of client files. Those data are being reviewed for trends and anomalies each month by the entire Quality Management Committee. From there, a summary report will be made available to the Board of Directors. Completion Date: February 20, 2020 Responsible Party: Thomas Aardahl, Executive Director
2019-007 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No. 2016-048550-003, Treatment Adult Services (TRA). Compliance ? Special Testing Criteria: TRA ? Residential Program requires a follow up 60-90 days after plan completion. Condition & Context: Of 40 client files reviewed, 6 lacked documentation of a follow up contact and 2 contained documentation of a follow-up contact more than 90 days after discharge. Cause: Of the 6 client files lacking documentation of follow up, 5 were for services provided after the retirement of the long-time program director and before her replacement was firmly established. Effect: Lack of follow-up contacts prevents accumulation of meaningful success rate statistics. Recommendation: Management should emphasize the need to complete and document each program requirement. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2019-007 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No. 2016-048550-003, Treatment Adult Services (TRA). Compliance ? Special Testing Criteria: TRA ? Residential Program requires a follow up 60-90 days after plan completion. Condition & Context: Of 40 client files reviewed, 6 lacked documentation of a follow up contact and 2 contained documentation of a follow-up contact more than 90 days after discharge. Cause: Of the 6 client files lacking documentation of follow up, 5 were for services provided after the retirement of the long-time program director and before her replacement was firmly established. Effect: Lack of follow-up contacts prevents accumulation of meaningful success rate statistics. Recommendation: Management should emphasize the need to complete and document each program requirement. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2019-006/007 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Compliance ? Special Testing Corrective Action Plan: We have updated our Quality Management Plan and established the Quality Management Committee, referenced in 2019-001 and 2019-002, that is responsible for coordinating monthly auditing of client files. Those data are being reviewed for trends and anomalies each month by the entire Quality Management Committee. From there, a summary report will be made available to the Board of Directors. Completion Date: February 20, 2020 Responsible Party: Thomas Aardahl, Executive Director
2019-008 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No. 2016-048550-003, Treatment Adult Services (TRA). Internal Control ? Monitoring Criteria: Monitoring should be such that there is an assurance that control activities are being performed in a timely manner. Conditions: Monitoring activities were not performed on a regular contemporaneous basis. Cause: As was the case with Internal Control Monitoring as referenced in Finding 2019-002 Monitoring of Federal Program Compliance was negatively impacted. The retirements and subsequent replacements of the chief executive officer and the program director negatively impacted the organizations monitoring effort in the area of program compliance. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: RCSETX?s management should consider establishing a formal monthly compliance review checklist including but not limited to program, compliance step, preparer initials, and date. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2019-008 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) U.S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Contract No. 2016-048550-003, Treatment Adult Services (TRA). Internal Control ? Monitoring Criteria: Monitoring should be such that there is an assurance that control activities are being performed in a timely manner. Conditions: Monitoring activities were not performed on a regular contemporaneous basis. Cause: As was the case with Internal Control Monitoring as referenced in Finding 2019-002 Monitoring of Federal Program Compliance was negatively impacted. The retirements and subsequent replacements of the chief executive officer and the program director negatively impacted the organizations monitoring effort in the area of program compliance. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: RCSETX?s management should consider establishing a formal monthly compliance review checklist including but not limited to program, compliance step, preparer initials, and date. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2019-008 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Internal Control over Compliance - Monitoring. Corrective Action Plan: See Quality Management Committee and Board of Directors referenced in 2019-006/007. Completion Date: February 20, 2020 Responsible Party: Thomas Aardahl, Executive Director
2018-008
FAC accepted this audit on May 5, 2019 — management decision was due November 5, 2019.
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