EIN: 741646979
UEI: RK6JY6LK3K13
Data as of August 25, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on July 20, 2026. 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 January 20, 2027 (148 days from today).
What is a management decision? →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. HHS000663700139, Treatment Adult Services (TRA) Outpatient and Residential and Contract No. HHS000663700187, Treatment Female Services (TRF) Outpatient and Residential. Compliance – Special Testing Criteria: TRA and TRF– Intensive Residential Program requires client follow up 60-90 days after plan completion. Condition and Context: Of 20 client files reviewed, (which represented 209 required components) 3 contained no discharge summary, 8 contained no discharge follow-up and 7 lacked a checklist that allows for monitoring. Cause: See explanation of Findings 2023-001. Effect: Lack of documentation of progress notes and discharge summary 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 ▴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. HHS000663700139, Treatment Adult Services (TRA) Outpatient and Residential and Contract No. HHS000663700187, Treatment Female Services (TRF) Outpatient and Residential. Compliance – Special Testing Criteria: TRA and TRF– Intensive Residential Program requires client follow up 60-90 days after plan completion. Condition and Context: Of 20 client files reviewed, (which represented 209 required components) 3 contained no discharge summary, 8 contained no discharge follow-up and 7 lacked a checklist that allows for monitoring. Cause: See explanation of Findings 2023-001. Effect: Lack of documentation of progress notes and discharge summary 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.
Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) - Compliance - Special Testing Corrective Action Plan: Quality Management Coordinator has conducted in-service training with staff members at the TRA and TRF facilities. Management will continue to emphasize, with the appropriate individuals, the need to complete and document, contemporaneously, each program requirement. Anticipated Completion Date: July 15, 2026 Responsible Party: Land Manor Executive Director, Quality Management Coordinator and Program Directors.
2022-003
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. HHS000663700139 (TRA) and Contract No. HHS000663700187 (TRF) Internal Control – Control Activities Criteria: Control Activities should be such that program compliance requirements are met on a timely basis and required reporting occurs contemporaneously. Condition, Cause and Effect: See Findings 2023-002. Recommendation: See Findings 2023-003. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴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. HHS000663700139 (TRA) and Contract No. HHS000663700187 (TRF) Internal Control – Control Activities Criteria: Control Activities should be such that program compliance requirements are met on a timely basis and required reporting occurs contemporaneously. Condition, Cause and Effect: See Findings 2023-002. Recommendation: See Findings 2023-003. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Control Activities Corrective Action Plan: The Corrective Action Plan referenced at 2023-002/003 will be expanded to include internal control over program compliance. The Monitoring Program being considered at 2023-001 would enhance compliance awareness on the part of program employees. Anticipated Completion Date: July 15, 2026 Responsible Party: Land Manor Executive Director, Quality Management Coordinator and Program Directors.
2022-004
Monitoring activities were not performed on regular contemporaneous basis. Cause: As was the case with Control Environment and Monitoring as referenced in Findings 2023-001 and 2023-002, Monitoring of Federal Program Compliance was negatively impacted by staff focus and failure to assign responsibility for the monitoring process. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: 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 ▴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. HHS000663700139 (TRA) and Contract No. HHS000663700187 (TRF) Internal Control – Monitoring Criteria: Monitoring should be such that there is an assurance that control activities are being performed in a timely manner. Condition: Monitoring activities were not performed on regular contemporaneous basis. Cause: As was the case with Control Environment and Monitoring as referenced in Findings 2023-001 and 2023-002, Monitoring of Federal Program Compliance was negatively impacted by staff focus and failure to assign responsibility for the monitoring process. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: 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.
Monitoring Corrective Action Plan: Each Program Director audits charts on a monthly basis and the Quality Management Coordinator audits them on a quarterly basis. Management continues to assess the need for a formal monthly compliance review checklist and has assigned its Quality Management Coordinator, a licensed counselor, to conduct Quality Assurance Reviews quarterly. Anticipated Completion Date: July 15, 2026 Responsible Party: Land Manor Executive Director, Quality Management Coordinator and Program Directors.
2022-005
FAC accepted this audit on October 26, 2022 — management decision was due April 26, 2023.
2021-003 ? 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 Nos. 2016-048494-003, Treatment Adult Services (TRA) Outpatient and Residential Compliance ? Special Testing Criteria: TRA ? Intensive Residential Program requires client follow up 60-90 days after plan completion. Condition & Context: Of 20 client files reviewed, (which represented 220 required components) 2 contained no discharge summary, and 9 lacked a checklist that allows for monitoring. Cause: See explanation of Findings 2021-001. Effect: Lack of documentation of progress notes and discharge summary 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 ▴2021-003 ? 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 Nos. 2016-048494-003, Treatment Adult Services (TRA) Outpatient and Residential Compliance ? Special Testing Criteria: TRA ? Intensive Residential Program requires client follow up 60-90 days after plan completion. Condition & Context: Of 20 client files reviewed, (which represented 220 required components) 2 contained no discharge summary, and 9 lacked a checklist that allows for monitoring. Cause: See explanation of Findings 2021-001. Effect: Lack of documentation of progress notes and discharge summary 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.
2021-003 - Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) - Compliance - Special Testing Corrective Action Plan: Quality Management Coordinator has conducted in-service training with staff members at the TRA and TRF facilities. Management will continue to emphasize, with the appropriate individuals, the need to complete and document, contemporaneously, each program requirement. Anticipated Completion Date: July 15, 2022 Responsible Party: Land Manor Executive Director; and, Quality Management Coordinator, Program Directors; and Carl White, Executive Director.
2020-003
2021-004 ? 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. 2016-048494-003 (TRA) Internal Control ? Control Activities Criteria: Control Activities should be such that program compliance requirements are met on a timely basis and required reporting occurs contemporaneously. Condition, Cause & Effect: See Findings 2021-002. Recommendation: See Findings 2021-003. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2021-004 ? 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. 2016-048494-003 (TRA) Internal Control ? Control Activities Criteria: Control Activities should be such that program compliance requirements are met on a timely basis and required reporting occurs contemporaneously. Condition, Cause & Effect: See Findings 2021-002. Recommendation: See Findings 2021-003. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2021-004 - Control Activities Corrective Action Plan: The Corrective Action Plan referenced at 2020-002/003 will be expanded to include internal control over program compliance. The Monitoring Program being considered at 2020-001 would enhance compliance awareness on the part of program employees. Anticipated Completion Date: July 15, 2022 Responsible Party: Land Manor Executive Director; and, Quality Management Coordinator, Program Directors; and Carl White, Executive Director.
2020-004
Monitoring activities were not performed on regular contemporaneous basis. Cause: As was the case with Control Environment and Monitoring as referenced in Findings 2021-001 and 2021-002, Monitoring of Federal Program Compliance was negatively impacted by staff focus and failure to assign responsibility for the monitoring process. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: 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 ▴2021-005 ? 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 Nos. 2016-048494-003 (TRA) Internal Control ? Monitoring Criteria: Monitoring should be such that there is an assurance that control activities are being performed in a timely manner. Condition: Monitoring activities were not performed on regular contemporaneous basis. Cause: As was the case with Control Environment and Monitoring as referenced in Findings 2021-001 and 2021-002, Monitoring of Federal Program Compliance was negatively impacted by staff focus and failure to assign responsibility for the monitoring process. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: 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.
2021-005 - Monitoring Corrective Action Plan: Each Program Director audits charts on a monthly basis and the Quality Management Coordinator audits them on a quarterly basis. Management continues to assess the need for a formal monthly compliance review checklist and has assigned its Quality Management Coordinator, a licensed counselor, to conduct Quality Assurance Reviews quarterly. Anticipated Completion Date: July 15, 2022 Responsible Party: Land Manor Executive Director; and, Quality Management Coordinator, Program Directors; and Carl White, Executive Director.
2020-005
2021-006 ? Compliance ? Texas Department of Criminal Justice, Residential and Outpatient Substance Abuse Treatment Services, Contract No. 696-PF-2021-C108 Compliance ? Special Testing Criteria: Patient files should contain the following: Signed Discharge Plan, Signed Aftercare Plan, Discharge Summary, Signed Initial Treatment Team Meeting Report, Signed 30-Day Treatment Meeting Report, Signed 60-Day Treatment Meeting Team Report, Signed Discharge Treatment Team Meeting Report, Authorization Management System Form, Monthly Progress Report, Monthly Program Attendance Records. Condition and Context: Of the patient files reviewed (which represents required components) several components were deficient. Of the component deficiencies noted, files were missing forms and signatures. The impacted files did contain evidence that an attempt was made to obtain these signatures. Cause: See explanation of Findings 2021-001 and 2021-002. Effect: Lack of documentation of completion of program requirements exposes Land Manor, Inc. to the risk of possible revenue refund requirements or reduction in future program funding. 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 ▴2021-006 ? Compliance ? Texas Department of Criminal Justice, Residential and Outpatient Substance Abuse Treatment Services, Contract No. 696-PF-2021-C108 Compliance ? Special Testing Criteria: Patient files should contain the following: Signed Discharge Plan, Signed Aftercare Plan, Discharge Summary, Signed Initial Treatment Team Meeting Report, Signed 30-Day Treatment Meeting Report, Signed 60-Day Treatment Meeting Team Report, Signed Discharge Treatment Team Meeting Report, Authorization Management System Form, Monthly Progress Report, Monthly Program Attendance Records. Condition and Context: Of the patient files reviewed (which represents required components) several components were deficient. Of the component deficiencies noted, files were missing forms and signatures. The impacted files did contain evidence that an attempt was made to obtain these signatures. Cause: See explanation of Findings 2021-001 and 2021-002. Effect: Lack of documentation of completion of program requirements exposes Land Manor, Inc. to the risk of possible revenue refund requirements or reduction in future program funding. 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.
2021-006 - Compliance Corrective Action Plan: Each Program Director audits charts on a monthly basis and the Quality Management Coordinator audits them on a quarterly basis. Management continues to assess the need for a formal monthly compliance review checklist and has assigned its Quality Management Coordinator, a licensed counselor, to conduct Quality Assurance Reviews quarterly. Anticipated Completion Date: July 15, 2022 Responsible Party: Management will coordinate for 2022 compliance as previously shown as a finding.
2020-006
FAC accepted this audit on June 28, 2021 — management decision was due December 28, 2021.
2020-003 ? 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 Nos. 2016-048494-003, Treatment Adult Services (TRA) Outpatient and Residential Compliance ? Special Testing Criteria: TRA ? Intensive Residential Program requires client follow up 60-90 days after plan completion. Condition & Context: Of 20 client files reviewed, (which represented 220 required components) 2 contained no discharge summary, and 6 lacked documentation of a follow up contact, 12 lacked a checklist that allows for monitoring. Cause: See explanation of Findings 2020-001. Effect: Lack of documentation of progress notes and discharge summary 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 ▴2020-003 ? 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 Nos. 2016-048494-003, Treatment Adult Services (TRA) Outpatient and Residential Compliance ? Special Testing Criteria: TRA ? Intensive Residential Program requires client follow up 60-90 days after plan completion. Condition & Context: Of 20 client files reviewed, (which represented 220 required components) 2 contained no discharge summary, and 6 lacked documentation of a follow up contact, 12 lacked a checklist that allows for monitoring. Cause: See explanation of Findings 2020-001. Effect: Lack of documentation of progress notes and discharge summary 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.
2020-003 - Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) - Compliance - Special Testing Corrective Action Plan: Quality Management Coordinator has conducted in-service training with staff members at the TRA and TRF facilities. Management will continue to emphasize, with the appropriate individuals, the need to complete and document, contemporaneously, each program requirement. Anticipated Completion Date: July 15, 2021 Responsible Party: Amanda Selemon, Associate Executive Director; Jessica Bean, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2019-008
2020-004 ? 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. 2016-048494-003 (TRA) Internal Control ? Control Activities Criteria: Control Activities should be such that program compliance requirements are met on a timely basis and required reporting occurs contemporaneously. Condition, Cause & Effect: See Findings 2020-002. Recommendation: See Findings 2020-003. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2020-004 ? 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. 2016-048494-003 (TRA) Internal Control ? Control Activities Criteria: Control Activities should be such that program compliance requirements are met on a timely basis and required reporting occurs contemporaneously. Condition, Cause & Effect: See Findings 2020-002. Recommendation: See Findings 2020-003. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2020-004 - Control Activities Corrective Action Plan: The Corrective Action Plan referenced at 2020-002/003 will be expanded to include internal control over program compliance. The Monitoring Program being considered at 2020-001 would enhance compliance awareness on the part of program employees. Anticipated Completion Date: July 15, 2021 Responsible Party: Amanda Selemon, Associate Executive Director; Jessica Bean, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2019-012
Monitoring activities were not performed on regular contemporaneous basis. Cause: As was the case with Control Environment and Monitoring as referenced in Findings 2020-001 and 2020-002, Monitoring of Federal Program Compliance was negatively impacted by staff focus and failure to assign responsibility for the monitoring process. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: 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 ▴2020-005 ? 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 Nos. 2016-048494-003 (TRA) Internal Control ? Monitoring Criteria: Monitoring should be such that there is an assurance that control activities are being performed in a timely manner. Condition: Monitoring activities were not performed on regular contemporaneous basis. Cause: As was the case with Control Environment and Monitoring as referenced in Findings 2020-001 and 2020-002, Monitoring of Federal Program Compliance was negatively impacted by staff focus and failure to assign responsibility for the monitoring process. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: 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.
2020-005 - Monitoring Corrective Action Plan: Each Program Director audits charts on a monthly basis and the Quality Management Coordinator audits them on a quarterly basis. Management continues to assess the need for a formal monthly compliance review checklist and has assigned its Quality Management Coordinator, a licensed counselor, to conduct Quality Assurance Reviews quarterly. Anticipated Completion Date: July 15, 2021 Responsible Party: Amanda Selemon, Associate Executive Director; Jessica Bean, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2019-013
FAC accepted this audit on February 24, 2020 — management decision was due August 24, 2020.
Two quarters of Financial Status Reports were not filed timely and two quarters of Financial Statement Reports along with Closeout Documents were not filed as of January, 2020. Cause: See explanation of Finding 2019-002. Effect: Lack of timely filing of required Financial Status Reports and Closeout Documents is a noncompliance issue that does not negatively impact our opinion on compliance, but which requires the auditee to take remedial action subsequent to the period under audit. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-004 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 ▴2019-006 ? 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 Nos.: 2016-048203-003 SA/HIV and 2016-048250-003 SA/HEI Compliance ? Reporting Criteria: Financial Status Reports (FSR077) were due quarterly, last business day of the month following the end of the quarter of the program and Closeout Documents were due 45 days after the Program Attachment end date. Condition: Two quarters of Financial Status Reports were not filed timely and two quarters of Financial Statement Reports along with Closeout Documents were not filed as of January, 2020. Cause: See explanation of Finding 2019-002. Effect: Lack of timely filing of required Financial Status Reports and Closeout Documents is a noncompliance issue that does not negatively impact our opinion on compliance, but which requires the auditee to take remedial action subsequent to the period under audit. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-004 to include quarterly and annual reporting requirements. 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 - Reporting Corrective Action Plan: Management will include quarterly and annual reporting requirements in its consideration of the monthly checklist referenced in Finding 2019-004. See CAP for that finding. Anticipated Completion Date: February 29, 2020 Responsible Party: William Stahl, Chief Financial Officer; Sheila Perez, Accounting Director; Julie King, Associate Executive Director; Amanda Selemon, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2018-006
Closeout Documents were not filed as of January, 2020. Cause: See explanation of Finding 2019-002. Effect: Lack of timely filing of required Closeout Documents is a noncompliance issue that does not negatively impact our opinion on compliance, but which requires the auditee to take remedial action subsequent to the period under audit. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-004 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 ▴2019-007 ? 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. 2016-048494-003, Treatment Services ? Adult (TRA) Outpatient and Residential and Contract No. 2016-048398-003 Treatment Services ? Adult Specialized Female (TRF) Outpatient and Residential Compliance ? Reporting Criteria: Financial Status Report (FSR077) 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. Condition: Closeout Documents were not filed as of January, 2020. Cause: See explanation of Finding 2019-002. Effect: Lack of timely filing of required Closeout Documents is a noncompliance issue that does not negatively impact our opinion on compliance, but which requires the auditee to take remedial action subsequent to the period under audit. Recommendation: Management should consider expanding the monthly checklist referenced in Finding 2019-004 to include quarterly and annual reporting requirements. 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 - Reporting Corrective Action Plan: Management will include quarterly and annual reporting requirements in its consideration of the monthly checklist referenced in Finding 2019-004. See CAP for that finding. Anticipated Completion Date: February 29, 2020 Responsible Party: William Stahl, Chief Financial Officer; Sheila Perez, Accounting Director; Julie King, Associate Executive Director; Amanda Selemon, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2018-007
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. 2016-048494-003, Treatment Adult Services (TRA) Outpatient and Residential Compliance ? Special Testing Criteria: TRA ? Intensive Residential Program requires client follow up 60-90 days after plan completion. Condition & Context: Of 6 client files reviewed, (which represented 66 required components) 1 was missing progress notes, 1 contained no discharge summary, and 5 contained documentation of a follow up contact, that occurred more than 90 days after discharge. Cause: See explanation of Finding 2019-001. Effect: Lack of documentation of progress notes and discharge summary 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 ▴2019-008 ? 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. 2016-048494-003, Treatment Adult Services (TRA) Outpatient and Residential Compliance ? Special Testing Criteria: TRA ? Intensive Residential Program requires client follow up 60-90 days after plan completion. Condition & Context: Of 6 client files reviewed, (which represented 66 required components) 1 was missing progress notes, 1 contained no discharge summary, and 5 contained documentation of a follow up contact, that occurred more than 90 days after discharge. Cause: See explanation of Finding 2019-001. Effect: Lack of documentation of progress notes and discharge summary 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.
2019-008/009/010 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Compliance ? Special Testing Corrective Action Plan: Quality Management Coordinator has conducted in-service training with staff members at the TRA and TRF facilities. Management will continue to emphasize, with the appropriate individuals, the need to complete and document, contemporaneously, each program requirement. Anticipated Completion Date: February 29, 2020 Responsible Party: Julie King, Associate Executive Director; Amanda Selemon, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2018-008
2019-009 ? 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. 2016-048398-003, Treatment Services ? Adult Specialized Female (TRF) Outpatient and Residential Compliance ? Special Testing Criteria: TRF Program client files should contain a Financial Eligibility Statement signed by the client. Condition & Context: Of 34 client files reviewed, 9 did not contain a signed Financial Eligibility Statement. Cause: See explanation of Findings 2019-002. Effect: The client files in question contained Eligibility Determination Results statements but lacked client signed affirmation. Recommendation: Same as Finding 2019-8. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
Show full finding ▾Hide full finding ▴2019-009 ? 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. 2016-048398-003, Treatment Services ? Adult Specialized Female (TRF) Outpatient and Residential Compliance ? Special Testing Criteria: TRF Program client files should contain a Financial Eligibility Statement signed by the client. Condition & Context: Of 34 client files reviewed, 9 did not contain a signed Financial Eligibility Statement. Cause: See explanation of Findings 2019-002. Effect: The client files in question contained Eligibility Determination Results statements but lacked client signed affirmation. Recommendation: Same as Finding 2019-8. View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan.
2019-008/009/010 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Compliance ? Special Testing Corrective Action Plan: Quality Management Coordinator has conducted in-service training with staff members at the TRA and TRF facilities. Management will continue to emphasize, with the appropriate individuals, the need to complete and document, contemporaneously, each program requirement. Anticipated Completion Date: February 29, 2020 Responsible Party: Julie King, Associate Executive Director; Amanda Selemon, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2018-009
2019-010 ? 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. 2016-048398-003, Treatment Services ? Adult Specialized Female (TRF) Outpatient and Residential Compliance ? Special Testing Criteria: TRF Outpatient and Residential Programs require a treatment plan, progress notes, client progress reviews halfway through the Treatment Plan, a Discharge Summary within 30 days of discharge and a follow up 60-90 days after plan completion. Condition & Context: Of 34 client files reviewed,(which represented 374 required components) 1 lacked a treatment plan and the plan was not prepared timely for 2 additional files, progress notes were not prepared timely in 1 file, 6 contained no mid-point review, 3 contained no Discharge Summary, 11 lacked documentation of a follow up contact, and an additional 5 contained follow up contact that occurred more than 90 days after discharge. Cause: See explanation of Finding 2019-002. Effect: Lack of the listed documentation 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 ▴2019-010 ? 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. 2016-048398-003, Treatment Services ? Adult Specialized Female (TRF) Outpatient and Residential Compliance ? Special Testing Criteria: TRF Outpatient and Residential Programs require a treatment plan, progress notes, client progress reviews halfway through the Treatment Plan, a Discharge Summary within 30 days of discharge and a follow up 60-90 days after plan completion. Condition & Context: Of 34 client files reviewed,(which represented 374 required components) 1 lacked a treatment plan and the plan was not prepared timely for 2 additional files, progress notes were not prepared timely in 1 file, 6 contained no mid-point review, 3 contained no Discharge Summary, 11 lacked documentation of a follow up contact, and an additional 5 contained follow up contact that occurred more than 90 days after discharge. Cause: See explanation of Finding 2019-002. Effect: Lack of the listed documentation 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.
2019-008/009/010 ? Block Grant for Prevention and Treatment of Substance Abuse (CFDA 93.959) ? Compliance ? Special Testing Corrective Action Plan: Quality Management Coordinator has conducted in-service training with staff members at the TRA and TRF facilities. Management will continue to emphasize, with the appropriate individuals, the need to complete and document, contemporaneously, each program requirement. Anticipated Completion Date: February 29, 2020 Responsible Party: Julie King, Associate Executive Director; Amanda Selemon, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2018-010
2019-011 ? 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 Nos. 2016 ? 048494-003 (TRA), 2016-048398-003 (TRF), 2016-048203-003 (SA/HIV) and 2016-048250-003 (SA/HEI) Internal Control ? Control Environment Criteria: See Finding 2019-001 Condition & Cause: See Finding 2019-001 Effect: Since the Control Environment is the foundation for all other elements of internal control over compliance, Control Activities and Monitoring related to internal control over compliance were limited. Recommendation: See Finding 2019-001 View of Responsible Party: See Corrective Action Plan
Show full finding ▾Hide full finding ▴2019-011 ? 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 Nos. 2016 ? 048494-003 (TRA), 2016-048398-003 (TRF), 2016-048203-003 (SA/HIV) and 2016-048250-003 (SA/HEI) Internal Control ? Control Environment Criteria: See Finding 2019-001 Condition & Cause: See Finding 2019-001 Effect: Since the Control Environment is the foundation for all other elements of internal control over compliance, Control Activities and Monitoring related to internal control over compliance were limited. Recommendation: See Finding 2019-001 View of Responsible Party: See Corrective Action Plan
2019-011 ? Control Environment Corrective Action Plan: Management will expand the corrective action plan discussed at 2019-001 to include the requisite personnel, program directors and the Quality Management Coordinator. Anticipated Completion Date: February 29, 2020 Responsible Party: Julie King, Associate Executive Director; Amanda Selemon, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2018-011
2019-012 ? 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 Nos. 2016 ? 048494-003 (TRA), 2016-048398-003 (TRF), 2016-048203-003 (SA/HIV) and 2016-048250-003 (SA/HEI) Internal Control ? Control Activities Criteria: Control Activities should be such that program compliance requirements are met on a timely basis and required reporting occurs contemporaneously. Condition, Cause & Effect: See Findings 2019-002 and 2019-003. Recommendation: See Finding 2019-003 View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan
Show full finding ▾Hide full finding ▴2019-012 ? 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 Nos. 2016 ? 048494-003 (TRA), 2016-048398-003 (TRF), 2016-048203-003 (SA/HIV) and 2016-048250-003 (SA/HEI) Internal Control ? Control Activities Criteria: Control Activities should be such that program compliance requirements are met on a timely basis and required reporting occurs contemporaneously. Condition, Cause & Effect: See Findings 2019-002 and 2019-003. Recommendation: See Finding 2019-003 View of Responsible Party: Management concurs with recommendation. See Corrective Action Plan
2019-012 ? Control Activities Corrective Action Plan: The Corrective Action Plan referenced at 2019-002/003 will be expanded to include internal control over program compliance. The Monitoring Program being considered at 2019-013 would enhance compliance awareness on the part of program employees. Anticipated Completion Date: February 29, 2020 Responsible Party: Julie King, Associate Executive Director; Amanda Selemon, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2018-012
2019-013 ? 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 Nos. 2016 ? 048494-003 (TRA), 2016-048398-003 (TRF), 2016-048203-003 (SA/HIV) and 2016-048250-003 (SA/HEI)- 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 Control Activities and Monitoring as referenced in Findings 2019-002, 2019-003 and 2019-004, Monitoring of Federal Program Compliance was negatively impacted by staff turnover and failure to assign responsibility for the monitoring process. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: 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 ▴2019-013 ? 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 Nos. 2016 ? 048494-003 (TRA), 2016-048398-003 (TRF), 2016-048203-003 (SA/HIV) and 2016-048250-003 (SA/HEI)- 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 Control Activities and Monitoring as referenced in Findings 2019-002, 2019-003 and 2019-004, Monitoring of Federal Program Compliance was negatively impacted by staff turnover and failure to assign responsibility for the monitoring process. Effect: As a result of these conditions, deficiencies in Program Compliance were not recognized on a timely basis. Recommendation: 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.
2019-013 ? Monitoring Corrective Action Plan: Each Program Director audits charts on a monthly basis and the Quality Management Coordinator audits them on a quarterly basis. Management continues to assess the need for a formal monthly compliance review checklist and has assigned its Quality Management Coordinator, a licensed counselor, to conduct Quality Assurance Reviews quarterly. See CAP under finding 2019-004. Anticipated Completion Date: February 29, 2020 Responsible Party: Julie King, Associate Executive Director; Amanda Selemon, Quality Management Coordinator; Jean Martinez, Program Director; Fernando Lozano, Program Director; John Dixon, Program Director; Carol Wallace, Program Director; and Carl White, Executive Director
2018-013
FAC accepted this audit on May 21, 2019 — management decision was due November 21, 2019.
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2017-004
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2017-004
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2017-004
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2017-004
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2017-004
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Show full finding ▾Hide full finding ▴FAC accepted this audit on June 27, 2018 — management decision was due December 27, 2018.
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2016-004
FAC accepted this audit on January 6, 2018 — management decision was due July 6, 2018.
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