Civic Heart Community Services

EIN: 760297531

UEI: DY23EUM3YRW5

Data as of August 23, 2026

Civic Heart Community Services10 audit years28 findings9 repeat
10
Audit Years
28
Total Findings
9
Repeat Findings

FY 2025-08-31

Management decision deadline — for entities that funded this organization

The FAC accepted this audit on May 26, 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 November 26, 2026 (94 days from today).

What is a management decision? →
2025-002
Cost Allowability / Reporting

Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Criteria: Reporting and allowable costs – Management of Civic Heart is responsible for establishing and maintaining an effective system of internal control over government grant billing requests to ensure all grant reimbursement requests are properly prepared and recorded and that all costs submitted for reimbursement are properly allocated, where applicable. Condition and context: Civic Heart’s internal controls over grant billing requests were not sufficient to ensure that grant billing requests were consistently independently reviewed and approved. Transaction testing for details and internal controls revealed the following: 1) 3 out of 12 grant billing requests did not have evidence of independent review and approval. 2) 3 of 3 pay period journal entries used to allocate payroll expense between departments and funding sources did not have evidence of independent review and approval. Cause and effect: Transitions in the accounting and management team resulted in independent reviews of grant billing requests and payroll allocation journal entries either not occurring or documentation of such review and approval not being retained. Failure to establish and maintain an adequate system of internal control over financial reporting adversely affects Civic Heart’s ability to prepare financial statements in accordance with GAAP and may result in improper grant billings. Questioned costs: Unknown. Recommendation: Same as finding reported as #2025-001. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Full finding narrative

Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Criteria: Reporting and allowable costs – Management of Civic Heart is responsible for establishing and maintaining an effective system of internal control over government grant billing requests to ensure all grant reimbursement requests are properly prepared and recorded and that all costs submitted for reimbursement are properly allocated, where applicable. Condition and context: Civic Heart’s internal controls over grant billing requests were not sufficient to ensure that grant billing requests were consistently independently reviewed and approved. Transaction testing for details and internal controls revealed the following: 1) 3 out of 12 grant billing requests did not have evidence of independent review and approval. 2) 3 of 3 pay period journal entries used to allocate payroll expense between departments and funding sources did not have evidence of independent review and approval. Cause and effect: Transitions in the accounting and management team resulted in independent reviews of grant billing requests and payroll allocation journal entries either not occurring or documentation of such review and approval not being retained. Failure to establish and maintain an adequate system of internal control over financial reporting adversely affects Civic Heart’s ability to prepare financial statements in accordance with GAAP and may result in improper grant billings. Questioned costs: Unknown. Recommendation: Same as finding reported as #2025-001. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: Civic Heart’s internal controls over grant billing requests were not sufficient to ensure that grant billing requests were consistently independently reviewed and approved. Transaction testing for details and internal controls revealed the following: 1) 3 out of 12 grant billing requests did not have evidence of independent review and approval. 2) 3 of 3 pay period journal entries used to allocate payroll expense between departments and funding sources did not have evidence of independent review and approval. Recommendation: Same as finding reported as #2025-001. Planned corrective action: Management has implemented enhanced grant reimbursement and compliance procedures designed to strengthen oversight, documentation standards, and review procedures. Corrective actions include: 1) Implementation of a formal grant reimbursement and drawdown review process requiring complete supporting documentation prior to submission. 2) Required supporting documentation now includes invoices, proof of payment, payroll documentation, time and effort certifications where applicable, budget verification, and grant period review. 3) All federal reimbursement requests require independent review and approval by the Chief Executive Officer prior to submission to ensure compliance with grant terms and conditions, Uniform Guidance requirements, federal regulations, and GAAP reporting standards. 4) Monthly grant compliance meetings are conducted to review reimbursement activity, grant expenditures, reporting deadlines, allowable costs, and budget variances. 5) Program and finance staff are participating in ongoing grant compliance training related to federal regulations, grant-specific requirements, documentation standards, allowable costs, and financial management procedures. Training efforts include periodic reviews and testing where applicable to reinforce compliance expectations. 6) Implementation of standardized grant tracking and reimbursement monitoring procedures to improve accountability and strengthen oversight. 7) Periodic internal compliance reviews of grant files, reimbursement requests, and supporting documentation to identify and address deficiencies proactively. Responsible officer: Anita Bates, Chief Executive Officer Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.

About Allowable Costs / Cost Principles, Reporting →
2025-003
Cost Allowability / Period of Performance
REPEATQUESTIONED COSTS

Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Criteria: Allowable costs and period of performance – The Uniform Guidance, Subpart E Cost Principles, establishes costs principles which must be followed for expenditures to be allowable and requires a system of internal controls sufficient to ensure that costs are properly charged to the appropriate general ledger object and class code. The Uniform Guidance §200.309 period of performance requires expenditures be incurred during the period of the federal grant award in order to be allowable. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost and other non-compliance: AL #93.092 Affordable Care Act (ACA) Personal Responsibility Education Program. In a sample of 40 non-payroll transactions tested for internal controls and compliance for allowable cost we found one instance of an annual subscription for the term ending May 2026 charged to a grant which ended September 29, 2025 resulting in eight months, or approximately $1,200, charged outside the period of performance. Partial repeat of finding #2024-004. Controls over period of performance and other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges. In a period-of-performance sample of 18 vendor transactions with grant charges close to grant beginning or ending dates during the audit period, we found 3 instances or $1,003 of vendor costs charged outside the grant period of performance. Additionally, testing of payroll charged at the end of the grant period revealed that approximately $6,693 was charged outside the period of performance. Cause and Effect: Failure to follow Civic Heart’s policies and procedures related to review of coding for charges to the grants resulted in costs charged outside the grant’s period of performance. Questioned costs: $8,896. Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance and review of payroll spreadsheets and general ledger coding for all transactions. View of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Full finding narrative

Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Criteria: Allowable costs and period of performance – The Uniform Guidance, Subpart E Cost Principles, establishes costs principles which must be followed for expenditures to be allowable and requires a system of internal controls sufficient to ensure that costs are properly charged to the appropriate general ledger object and class code. The Uniform Guidance §200.309 period of performance requires expenditures be incurred during the period of the federal grant award in order to be allowable. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost and other non-compliance: AL #93.092 Affordable Care Act (ACA) Personal Responsibility Education Program. In a sample of 40 non-payroll transactions tested for internal controls and compliance for allowable cost we found one instance of an annual subscription for the term ending May 2026 charged to a grant which ended September 29, 2025 resulting in eight months, or approximately $1,200, charged outside the period of performance. Partial repeat of finding #2024-004. Controls over period of performance and other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges. In a period-of-performance sample of 18 vendor transactions with grant charges close to grant beginning or ending dates during the audit period, we found 3 instances or $1,003 of vendor costs charged outside the grant period of performance. Additionally, testing of payroll charged at the end of the grant period revealed that approximately $6,693 was charged outside the period of performance. Cause and Effect: Failure to follow Civic Heart’s policies and procedures related to review of coding for charges to the grants resulted in costs charged outside the grant’s period of performance. Questioned costs: $8,896. Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance and review of payroll spreadsheets and general ledger coding for all transactions. View of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost and other non-compliance: AL #93.092 Affordable Care Act (ACA) Personal Responsibility Education Program. In a sample of 40 non-payroll transactions tested for internal controls and compliance for allowable cost we found one instance of an annual subscription for the term ending May 2026 charged to a grant which ended September 29, 2025 resulting in eight months, or approximately $1,200, charged outside the period of performance. Partial repeat of finding #2024-004. Controls over period of performance and other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges. In a period-of-performance sample of 18 vendor transactions with grant charges close to grant beginning or ending dates during the audit period, we found 3 instances or $1,003 of vendor costs charged outside the grant period of performance. Additionally, testing of payroll charged at the end of the grant period revealed that approximately $6,693 was charged outside the period of performance. Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance and review of payroll spreadsheets and general ledger coding for all transactions. Planned corrective action: Management has implemented strengthened procedures related to payroll allocations, grant coding, allowable costs review, and monitoring of grant periods of performance. Corrective actions include: 1) Enhanced review procedures to ensure expenditures are charged to the appropriate funding source and grant period. 2) Review of payroll allocations against approved grant budgets and supporting time and effort certifications where applicable. 3) Monthly review meetings between finance personnel and program leadership to review coding accuracy, budget status, payroll allocations, and grant compliance requirements. 4) Additional staff training related to Uniform Guidance cost principles, allowable costs, grant periods of performance, and GAAP financial reporting requirements. 5) Improved grant expenditure tracking and monitoring procedures to identify coding errors or compliance concerns timely. 6) Strengthened documentation retention procedures to ensure expenditures are properly supported and audit ready. Responsible officer: Anita Bates, Chief Executive Officer. Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.

Prior Finding References

2024-004

About Allowable Costs / Cost Principles, Period of Performance →
2025-004
Reporting

Finding #2025-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Criteria: Reporting – The Uniform Guidance §200.508 and §200.510 requires management to prepare a schedule of expenditures of federal wards (SEFA) for the period covered by the auditee’s financial statements which must include the total federal awards expended and amounts expended by subrecipients. Management is responsible for establishing and maintaining an effective system of internal control sufficient to prepare the SEFA in accordance with Uniform Guidance. Condition and context: Civic Heart had not performed a reconciliation of federal expenditures resulting in errors in reported expenditures. Additionally, subrecipient expenditures were not identified for two programs. There was no independent review of the SEFA. During the audit of the 2025 fiscal year, it was noted that the SEFA for the year ended August 31, 2024 overstated expenditures for the HIV Prevention Activities – Non-Governmental Organizational Based program (AL #93.939) by $52,013. The 2024 SEFA included expenditures that were allowable in accordance with the grant agreement but not billed to the federal agency for reimbursement. An audit adjustment reducing the current year expenditures was required. Cause: Transitions in the accounting and management team resulted in failure to follow Civic Heart’s policies and procedures related to preparation and review of the SEFA. Effect: Adjustments of approximately $52,600 were required to properly report expenditures and adjustments of approximately $76,600 were required to properly report subrecipient expenditures on the SEFA. Recommendation: Emphasize adherence to established policies and procedures to reconcile the federal expenditures to the federal program revenue on a routine basis and formalize the independent review process for the SEFA and grant billings. View of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Full finding narrative

Finding #2025-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Criteria: Reporting – The Uniform Guidance §200.508 and §200.510 requires management to prepare a schedule of expenditures of federal wards (SEFA) for the period covered by the auditee’s financial statements which must include the total federal awards expended and amounts expended by subrecipients. Management is responsible for establishing and maintaining an effective system of internal control sufficient to prepare the SEFA in accordance with Uniform Guidance. Condition and context: Civic Heart had not performed a reconciliation of federal expenditures resulting in errors in reported expenditures. Additionally, subrecipient expenditures were not identified for two programs. There was no independent review of the SEFA. During the audit of the 2025 fiscal year, it was noted that the SEFA for the year ended August 31, 2024 overstated expenditures for the HIV Prevention Activities – Non-Governmental Organizational Based program (AL #93.939) by $52,013. The 2024 SEFA included expenditures that were allowable in accordance with the grant agreement but not billed to the federal agency for reimbursement. An audit adjustment reducing the current year expenditures was required. Cause: Transitions in the accounting and management team resulted in failure to follow Civic Heart’s policies and procedures related to preparation and review of the SEFA. Effect: Adjustments of approximately $52,600 were required to properly report expenditures and adjustments of approximately $76,600 were required to properly report subrecipient expenditures on the SEFA. Recommendation: Emphasize adherence to established policies and procedures to reconcile the federal expenditures to the federal program revenue on a routine basis and formalize the independent review process for the SEFA and grant billings. View of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2025-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: Civic Heart had not performed a reconciliation of federal expenditures resulting in errors in reported expenditures. Additionally, subrecipient expenditures were not identified for two programs. There was no independent review of the SEFA. Recommendation: Emphasize adherence to established policies and procedures to reconcile the federal expenditures to the federal program revenue on a routine basis and formalize the independent review process for the SEFA and grant billings. Planned corrective action: Management has implemented strengthened federal reporting and reconciliation procedures to improve accuracy and oversight related to federal expenditures and SEFA preparation. Corrective actions include: 1) Implementation of a formal SEFA preparation and reconciliation process requiring reconciliation of federal expenditures to the general ledger and supporting documentation. 2) Quarterly federal expenditure reviews to identify discrepancies and improve reporting accuracy throughout the fiscal year. 3) Development of centralized federal awards tracking procedures to monitor expenditures, reimbursement activity, subrecipient activity, grant balances, and reporting requirements. 4) Independent review procedures for preparation and review of the SEFA prior to annual audit submission. 5) Strengthened coordination between accounting personnel and program leadership to improve federal reporting accuracy and monitoring of subrecipient activity. 6) Periodic internal compliance reviews to evaluate federal reporting accuracy and compliance with grant requirements. Responsible officer: Anita Bates, Chief Executive Officer. Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.

About Reporting →

FY 2024-08-31

FAC accepted this audit on May 29, 2025 — management decision was due November 29, 2025.

2024-003
Cost Allowability
MATERIAL WEAKNESSREPEAT

Finding #2024-003 – Material Weakness and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-03-03, Contract year: 08/27/23 – 08/26/24, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Children’s Health Insurance Program, Assistance Listing #93.767, Contract #2Y2CMS331859-02-05, Contract year: 07/01/23 – 06/30/25. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPS, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPU, Contract year: 09/01/23 – 08/31/24. Criteria: Allowable costs – The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, §200.430 requires that charges to awards for salaries and wages be based on records that accurately reflect the work performed. These records must: 1) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable and properly allocated; 2) reasonably reflect the total activity for which the employee is compensated; 3) comply with the established accounting policies and practices of the agency; and 4) support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one activity. Without sufficient controls, costs may be inappropriately charged to a federal award. Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain shared costs are impacted as they are charged to the program based on the direct salary percentages. Repeat of finding #2023-001. Cause: Prior to the audit finding reported to management in May 2023, management had a lack of understanding regarding the requirements for charging payroll costs caused improper reporting of time incurred on the federal awards. Effect: Failure to establish controls for adherence with the Uniform Guidance for allowable costs may result in unallowed costs charged to the program. Questioned costs: Unknown. Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Full finding narrative

Finding #2024-003 – Material Weakness and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-03-03, Contract year: 08/27/23 – 08/26/24, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Children’s Health Insurance Program, Assistance Listing #93.767, Contract #2Y2CMS331859-02-05, Contract year: 07/01/23 – 06/30/25. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPS, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPU, Contract year: 09/01/23 – 08/31/24. Criteria: Allowable costs – The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, §200.430 requires that charges to awards for salaries and wages be based on records that accurately reflect the work performed. These records must: 1) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable and properly allocated; 2) reasonably reflect the total activity for which the employee is compensated; 3) comply with the established accounting policies and practices of the agency; and 4) support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one activity. Without sufficient controls, costs may be inappropriately charged to a federal award. Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain shared costs are impacted as they are charged to the program based on the direct salary percentages. Repeat of finding #2023-001. Cause: Prior to the audit finding reported to management in May 2023, management had a lack of understanding regarding the requirements for charging payroll costs caused improper reporting of time incurred on the federal awards. Effect: Failure to establish controls for adherence with the Uniform Guidance for allowable costs may result in unallowed costs charged to the program. Questioned costs: Unknown. Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2024-003 – Material Weakness and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-03-03, Contract year: 08/27/23 – 08/26/24, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Children’s Health Insurance Program, Assistance Listing #93.767, Contract #2Y2CMS331859-02-05, Contract year: 07/01/23 – 06/30/25. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPS, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPU, Contract year: 09/01/23 – 08/31/24. Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain shared costs are impacted as they are charged to the program based on the direct salary percentages. Repeat of finding #2023-001. Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Planned corrective action: Management implemented new controls and procedures in June 2024 to fully comply with time and effort reporting as required by Uniform Guidance. Salaries and wages charged to the grant are now based on actual work performed determined by hours submitted by employee and approved by the applicable supervisor. Policies and procedures have been updated to include this required process to ensure that the allocation methodology used to allocate costs between programs reflect the actual relative benefit to the grant. Responsible officer: Angelica Castillo, CFO. Estimated completion date: Completed.

Prior Finding References

2023-001

About Allowable Costs / Cost Principles →
2024-004
Cost Allowability / Period of Performance
QUESTIONED COSTS

Finding #2024-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-03-03, Contract year: 08/27/23 – 08/26/24, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Children’s Health Insurance Program, Assistance Listing #93.767, Contract #2Y2CMS331859-02-05, Contract year: 07/01/23 – 06/30/25. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPS, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPU, Contract year: 09/01/23 – 08/31/24. Criteria: Allowable costs and period of performance – The Uniform Guidance, Subpart E Cost Principles, establishes costs principles which must be followed for expenditures to be allowable and requires a system of internal controls sufficient to ensure that costs are properly charged to the appropriate general ledger object and class code. The Uniform Guidance §200.309 period of performance requires expenditures be incurred during the period of the federal grant award in order to be allowable. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost compliance – all major programs, In a sample of 59 non-payroll transactions tested for internal controls over compliance: One instance of annual advertising contract charged in full rather than establishing a prepaid expense for the eleven months after Civic Heart’s year-end of August 31, 2024. The applicable grant period is July 1, 2023 through June 30, 2025 and thus, only one month, or approximately $417, was outside the period of performance (AL #93.767 Children’s Health Insurance Program). One instance of $2,700 charged to wrong program. Allowable costs of the Navigator program were charged to Connecting Kids program due to coding to the wrong class code in the general ledger. (AL#93.767 Children’s Health Insurance Program (Connecting Kids). In a sample of 135 payroll transactions tested for internal controls over compliance: Four instances of errors in the amount of costs charged to class code due to a clerical error in the payroll allocation spreadsheet. (AL #93.959 Block Grants for Prevention and Treatment of Substance Abuse and AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based). Other non-compliance: AL #93.767 Children’s Health Insurance Program: In a sample of 40 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($417). AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 42 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($2,700). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based: In a sample of 40 payroll or vendor charges, two instances of non-compliance with allowable costs due to charge to the wrong program. Controls over period of performance – all major programs. In a sample of 56 vendor transactions and 4 pay periods with grant beginning or ending dates during the audit period, we found: 13 instances of charging vendor costs to the wrong grant period. One instance of charging payroll costs to the wrong grant period. Other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 14 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $3,120). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based. In a sample of 27 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $480). In a sample of four pay periods tested, we found one exception for charging costs to the wrong grant period (approximately $5,350). AL# 93.959 Block Grants for Prevention and Treatment of Substance Abuse. In a sample of 25 vendor charges tested, we found 5 exceptions for charging to the wrong grant period (approximately $660). Cause: Failure to follow Civic Heart’s policies and procedures related to review of coding for charges to the general ledger. Effect: Failure to follow established internal control policies and procedures resulted in errors and unallowable costs being charged to the grant. Questioned costs: $12,727. Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance of payroll spreadsheets and reviews of coding for all transactions. View of responsible officials: Management agrees with the finding. See Corrective Action Plan.

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Finding #2024-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-03-03, Contract year: 08/27/23 – 08/26/24, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Children’s Health Insurance Program, Assistance Listing #93.767, Contract #2Y2CMS331859-02-05, Contract year: 07/01/23 – 06/30/25. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPS, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPU, Contract year: 09/01/23 – 08/31/24. Criteria: Allowable costs and period of performance – The Uniform Guidance, Subpart E Cost Principles, establishes costs principles which must be followed for expenditures to be allowable and requires a system of internal controls sufficient to ensure that costs are properly charged to the appropriate general ledger object and class code. The Uniform Guidance §200.309 period of performance requires expenditures be incurred during the period of the federal grant award in order to be allowable. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost compliance – all major programs, In a sample of 59 non-payroll transactions tested for internal controls over compliance: One instance of annual advertising contract charged in full rather than establishing a prepaid expense for the eleven months after Civic Heart’s year-end of August 31, 2024. The applicable grant period is July 1, 2023 through June 30, 2025 and thus, only one month, or approximately $417, was outside the period of performance (AL #93.767 Children’s Health Insurance Program). One instance of $2,700 charged to wrong program. Allowable costs of the Navigator program were charged to Connecting Kids program due to coding to the wrong class code in the general ledger. (AL#93.767 Children’s Health Insurance Program (Connecting Kids). In a sample of 135 payroll transactions tested for internal controls over compliance: Four instances of errors in the amount of costs charged to class code due to a clerical error in the payroll allocation spreadsheet. (AL #93.959 Block Grants for Prevention and Treatment of Substance Abuse and AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based). Other non-compliance: AL #93.767 Children’s Health Insurance Program: In a sample of 40 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($417). AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 42 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($2,700). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based: In a sample of 40 payroll or vendor charges, two instances of non-compliance with allowable costs due to charge to the wrong program. Controls over period of performance – all major programs. In a sample of 56 vendor transactions and 4 pay periods with grant beginning or ending dates during the audit period, we found: 13 instances of charging vendor costs to the wrong grant period. One instance of charging payroll costs to the wrong grant period. Other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 14 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $3,120). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based. In a sample of 27 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $480). In a sample of four pay periods tested, we found one exception for charging costs to the wrong grant period (approximately $5,350). AL# 93.959 Block Grants for Prevention and Treatment of Substance Abuse. In a sample of 25 vendor charges tested, we found 5 exceptions for charging to the wrong grant period (approximately $660). Cause: Failure to follow Civic Heart’s policies and procedures related to review of coding for charges to the general ledger. Effect: Failure to follow established internal control policies and procedures resulted in errors and unallowable costs being charged to the grant. Questioned costs: $12,727. Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance of payroll spreadsheets and reviews of coding for all transactions. View of responsible officials: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2024-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-03-03, Contract year: 08/27/23 – 08/26/24, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Children’s Health Insurance Program, Assistance Listing #93.767, Contract #2Y2CMS331859-02-05, Contract year: 07/01/23 – 06/30/25. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPS, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPU, Contract year: 09/01/23 – 08/31/24. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost compliance – all major programs. In a sample of 59 non-payroll transactions tested for internal controls over compliance: One instance of annual advertising contract charged in full rather than establishing a prepaid expense for the eleven months after Civic Heart’s year-end of August 31, 2024. The applicable grant period is July 1, 2023 through June 30, 2025 and thus, only one month, or approximately $417, was outside the period of performance (AL #93.767 Children’s Health Insurance Program). One instance of $2,700 charged to wrong program. Allowable costs of the Navigator program were charged to Connecting Kids program due to coding to the wrong class code in the general ledger. (AL#93.767 Children’s Health Insurance Program (Connecting Kids). In a sample of 135 payroll transactions tested for internal controls over compliance: Four instances of errors in the amount of costs charged to class code due to a clerical error in the payroll allocation spreadsheet. (AL #93.959 Block Grants for Prevention and Treatment of Substance Abuse and AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based). Other non-compliance: AL #93.767 Children’s Health Insurance Program: In a sample of 40 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($417). AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 42 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($2,700). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based: In a sample of 40 payroll or vendor charges, two instances of non-compliance with allowable costs due to charge to the wrong program. Controls over period of performance – all major programs. In a sample of 56 vendor transactions and 4 pay periods with grant beginning or ending dates during the audit period, we found: 13 instances of charging vendor costs to the wrong grant period. One instance of charging payroll costs to the wrong grant period. Other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 14 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $3,120). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based. In a sample of 27 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $480). In a sample of four pay periods tested, we found one exception for charging costs to the wrong grant period (approximately $5,350). AL# 93.959 Block Grants for Prevention and Treatment of Substance Abuse. In a sample of 25 vendor charges tested, we found 5 exceptions for charging to the wrong grant period (approximately $660). Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance of payroll spreadsheets and reviews of coding for all transactions. Planned corrective action: Adherence to established policies and procedures will be strengthened by providing additional training when onboarding accounting staff, as well as additional oversight to the disbursement and payroll process. New accounting staff will be more thoroughly trained on established policies and procedures, including accruals, proper financial statement period recognition, grant award period of performance, tracking of grant activities using class codes, and allowable cost requirements. In addition, the CFO will ensure sufficient time is dedicated to reconciling payroll spreadsheets, payroll allocations, period of performance, and payroll accruals. Salaries and wages charged to the grant are now based on actual work performed determined by hours submitted by employee and approved by the applicable supervisor; this new control should assist in mitigating posting errors related to incorrect grants and grant periods. Responsible officer: Angelica Castillo, CFO. Estimated completion date: June 30, 2025.

About Allowable Costs / Cost Principles, Period of Performance →
2024-005
Special Tests & Provisions

Finding #2024-005 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. Criteria: Special Tests and Provisions – Federal regulations require Civic Heart to provide referral services to HIV positive clients. Clients who refuse referrals must receive three documented attempts to receive the referral. If the referral is not accepted, the client must be referred to Disease Intervention Specialists (DIS) with the Centers for Disease Control and Prevention and the referral must be documented in the client’s file within 30 days. Condition and context: During our testing of 40 client case files, we noted one HIV positive client where there was no documentation of declined referrals sent to DIS. Cause: The finding occurred as a result of Civic Heart’s failure to follow its policies and procedures and federal regulations. Effect: Failure to retain referral documentation can result in unallowable costs. Recommendation: Re-emphasize procedures to ensure proper retention of referral documentation. Views of responsible officials and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2024-005 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. Criteria: Special Tests and Provisions – Federal regulations require Civic Heart to provide referral services to HIV positive clients. Clients who refuse referrals must receive three documented attempts to receive the referral. If the referral is not accepted, the client must be referred to Disease Intervention Specialists (DIS) with the Centers for Disease Control and Prevention and the referral must be documented in the client’s file within 30 days. Condition and context: During our testing of 40 client case files, we noted one HIV positive client where there was no documentation of declined referrals sent to DIS. Cause: The finding occurred as a result of Civic Heart’s failure to follow its policies and procedures and federal regulations. Effect: Failure to retain referral documentation can result in unallowable costs. Recommendation: Re-emphasize procedures to ensure proper retention of referral documentation. Views of responsible officials and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2024-005 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. Condition and context: During our testing of 40 client case files, we noted one HIV positive client where there was no documentation of declined referrals sent to Disease Intervention Specialists. Recommendation: Re-emphasize procedures to ensure proper retention of referral documentation. Planned corrective action: The HIV/Wellness program previously contracted an external health professional to review positive files for quality management. The program temporarily transitioned between health professionals to support the need for more frequent reviews. Steps missed by internal staff were identified but were not identified during the quality management transition as timely reviews were not conducted. Program leadership has taken action to review policies and procedures to include HIV positive client support timelines. An additional procedure has been added which requires faxing client forms to local health department using secure steps provided by the local health department. Faxed forms are placed in client file and will serve as proof of referral and date referred. An additional review of files for proper documentation has been added and will be performed by medical student interns. Responsible officer: Kelva Clay, CPO. Estimated completion date: Completed.

About Special Tests and Provisions →

FY 2023-08-31

FAC accepted this audit on May 23, 2024 — management decision was due November 23, 2024.

2023-001
Cost Allowability
MATERIAL WEAKNESSREPEAT

Finding #2023-001 – Material Weakness and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-02-02, Contract year: 08/27/22 – 08/26/23, Contract #NAVCA210403-03-00, Contract year: 08/27/23 – 08/26/24. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPS, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPU, Contract year: 09/01/22 – 08/31/23. Criteria: Allowable costs – The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, §200.430 requires that charges to awards for salaries and wages be based on records that accurately reflect the work performed. These records must: 1) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable and properly allocated; 2) reasonably reflect the total activity for which the employee is compensated; 3) comply with the established accounting policies and practices of the agency; and 4) support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one activity. Without sufficient controls, costs may be inappropriately charged to a federal funding stream. Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain costs are impacted as they are charged to the program based on the direct salary percentages. Repeat of finding #2022-001. Cause: Prior to the audit finding reported to management in May 2023, management had a lack of understanding regarding the requirements for charging payroll costs caused improper reporting of time incurred on the federal awards. Management is working to implement new controls and procedures to fully comply with time and effort reporting as required by Uniform Guidance. Effect: Failure to establish controls for adherence with the Uniform Guidance for allowable costs may result in unallowed costs charged to the program. Questioned costs: Unknown. Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2023-001 – Material Weakness and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-02-02, Contract year: 08/27/22 – 08/26/23, Contract #NAVCA210403-03-00, Contract year: 08/27/23 – 08/26/24. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPS, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPU, Contract year: 09/01/22 – 08/31/23. Criteria: Allowable costs – The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, §200.430 requires that charges to awards for salaries and wages be based on records that accurately reflect the work performed. These records must: 1) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable and properly allocated; 2) reasonably reflect the total activity for which the employee is compensated; 3) comply with the established accounting policies and practices of the agency; and 4) support the distribution of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one activity. Without sufficient controls, costs may be inappropriately charged to a federal funding stream. Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain costs are impacted as they are charged to the program based on the direct salary percentages. Repeat of finding #2022-001. Cause: Prior to the audit finding reported to management in May 2023, management had a lack of understanding regarding the requirements for charging payroll costs caused improper reporting of time incurred on the federal awards. Management is working to implement new controls and procedures to fully comply with time and effort reporting as required by Uniform Guidance. Effect: Failure to establish controls for adherence with the Uniform Guidance for allowable costs may result in unallowed costs charged to the program. Questioned costs: Unknown. Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2023-001 – Material Weakness and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-02-02, Contract year: 08/27/22 – 08/26/23, Contract #NAVCA210403-03-00, Contract year: 08/27/23 – 08/26/24. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPS, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPU, Contract year: 09/01/22 – 08/31/23. Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain costs are impacted as they are charged to the program based on the direct salary percentages. Repeat of finding #2022-001. Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Planned corrective action: Salaries and wages charged to the grant will be based on actual work performed determined by hours submitted by employee and approved by the applicable supervisor. Policies and procedures have been updated to include this required process to ensure that the allocation methodology used to allocate costs between programs reflect the actual relative benefit to the grant. Training will be provided to program and accounting staff to review the updated policies and procedures and to ensure implementation is complete. Responsible officer: Angelica Castillo, CFO. Estimated completion date: June 1, 2024.

Prior Finding References

2022-001

About Allowable Costs / Cost Principles →
2023-002
Procurement & Suspension/Debarment
REPEAT

Finding #2023-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Housing and Urban Development, Direct Federal Funding, Continuum of Care Program, Assistance Listing #14.267, Contract # TX0392L6E002107, Contract year: 09/01/22 – 08/31/23. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-02-02, Contract year: 08/27/22 – 08/26/23, Contract #NAVCA210403-03-00, Contract year: 08/27/23 – 08/26/24. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPS, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPU, Contract year: 09/01/22 – 08/31/23. Criteria: Procurement and Suspension and Debarment – The Uniform Guidance §180 prohibits contracting with parties that are suspended or debarred. The determination of whether the contracting party is suspended or debarred or otherwise excluded from participating in the transaction may be made by checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration. Condition and context: Civic Heart amended its procurement policy in July 2023 to include a provision that Civic Heart will restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible. Although, Civic Heart was unable to provide evidence that such verification had been made during fiscal year 2023, we tested a sample of 13 vendors and found none to be suspended or debarred. Partial repeat of finding #2022-002. Cause: Civic Heart amended its procurement policy eleven months into fiscal year 2023 as a result of the 2022 audit finding. Although the policy was amended, the provision requiring verification of lack of suspension and debarment was not placed into service until after August 31, 2023. Effect: Failure to follow all requirements of Civic Heart’s procurement policy, including verification of lack of suspension and debarment could result in selecting vendors who are not eligible to be paid with federal monies. Recommendation: Implement procedures and provide training to personnel regarding verification that potential vendors are not debarred, suspended, or otherwise excluded from or ineligible for participation as required by their procurement policy. Views of responsible officials and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2023-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Housing and Urban Development, Direct Federal Funding, Continuum of Care Program, Assistance Listing #14.267, Contract # TX0392L6E002107, Contract year: 09/01/22 – 08/31/23. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-02-02, Contract year: 08/27/22 – 08/26/23, Contract #NAVCA210403-03-00, Contract year: 08/27/23 – 08/26/24. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPS, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPU, Contract year: 09/01/22 – 08/31/23. Criteria: Procurement and Suspension and Debarment – The Uniform Guidance §180 prohibits contracting with parties that are suspended or debarred. The determination of whether the contracting party is suspended or debarred or otherwise excluded from participating in the transaction may be made by checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration. Condition and context: Civic Heart amended its procurement policy in July 2023 to include a provision that Civic Heart will restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible. Although, Civic Heart was unable to provide evidence that such verification had been made during fiscal year 2023, we tested a sample of 13 vendors and found none to be suspended or debarred. Partial repeat of finding #2022-002. Cause: Civic Heart amended its procurement policy eleven months into fiscal year 2023 as a result of the 2022 audit finding. Although the policy was amended, the provision requiring verification of lack of suspension and debarment was not placed into service until after August 31, 2023. Effect: Failure to follow all requirements of Civic Heart’s procurement policy, including verification of lack of suspension and debarment could result in selecting vendors who are not eligible to be paid with federal monies. Recommendation: Implement procedures and provide training to personnel regarding verification that potential vendors are not debarred, suspended, or otherwise excluded from or ineligible for participation as required by their procurement policy. Views of responsible officials and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2023-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Housing and Urban Development, Direct Federal Funding, Continuum of Care Program, Assistance Listing #14.267, Contract # TX0392L6E002107, Contract year: 09/01/22 – 08/31/23. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-02-02, Contract year: 08/27/22 – 08/26/23, Contract #NAVCA210403-03-00, Contract year: 08/27/23 – 08/26/24. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPS, Contract year: 09/01/22 – 08/31/23, Contract #HHS000539700204 YPU, Contract year: 09/01/22 – 08/31/23. Condition and context: Civic Heart amended its procurement policy in July 2023 to include a provision that Civic Heart will restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible. Although, Civic Heart was unable to provide evidence that such verification had been made during fiscal year 2023, we tested a sample of 13 vendors and found none to be suspended or debarred. Partial repeat of finding #2022-002. Recommendation: Implement procedures and provide training to personnel regarding verification that potential vendors are not debarred, suspended, or otherwise excluded from or ineligible for participation as required by their procurement policy. Planned corrective action: Procedures have been implemented and training has been provided to personnel regarding determination of suspension or debarment of vendors as required by the Uniform Guidance. Although determination was performed for all applicable vendors and none were determined to be debarred, suspended, or otherwise excluded from or ineligible for participation, determination was performed after the end of fiscal year 2023. The determination process is now required to be performed prior to vendor selection and supporting documentation is to be dated and maintained in agency files. Responsible officer: Angelica Castillo, CFO. Estimated completion date: October 1, 2023

Prior Finding References

2022-002

About Procurement and Suspension and Debarment →

FY 2022-08-31

FAC accepted this audit on May 21, 2023 — management decision was due November 21, 2023.

2022-001
Cost Allowability
MATERIAL WEAKNESS

Finding #2022-001 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Direct Federal Funding Continuum of Care Program Assistance Listing #14.267 Contract #TX0392L6E002006, Contract year: 09/01/21 ? 08/31/22 U. S. Department of Health and Human Services Direct Federal Funding Sexual Risk Avoidance Education Assistance Listing #93.060 Contract #90SR0044-03-03, Contract year: 09/30/20 ? 06/30/22 Contract #90SR0120-01-00, Contract year: 09/30/20 ? 09/29/21 Contract #90SR0120-02-00, Contract year: 09/30/21 ? 09/29/22 Contract #90SR0157-01-01, Contract year: 09/30/21 ? 09/29/22 U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #HHS000539700204 YPI, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPS, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPU, Contract year: 09/01/21 ? 08/31/22 Criteria: Allowable costs ? The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, ?200.430 requires that charges to awards for salaries and wages be based on records that accurately reflect the work performed. These records must: 1) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable and properly allocated; 2) reasonably reflect the total activity for which the employee is compensated; 3) comply with the established accounting policies and practices of the agency; and 4) support the distribution of the employee?s salary or wages among specific activities or cost objectives if the employee works on more than one activity. Without sufficient controls, costs may be inappropriately charged to a federal funding stream. Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain costs are impacted as they are charged to the program based on the direct salary percentages. Cause: Management?s lack of understanding regarding the requirements for charging payroll costs caused improper reporting of time incurred on the federal awards. Effect: Failure to establish controls for adherence with the Uniform Guidance for allowable costs may result in unallowed costs charged to the program. Questioned costs: Unknown Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2022-001 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Direct Federal Funding Continuum of Care Program Assistance Listing #14.267 Contract #TX0392L6E002006, Contract year: 09/01/21 ? 08/31/22 U. S. Department of Health and Human Services Direct Federal Funding Sexual Risk Avoidance Education Assistance Listing #93.060 Contract #90SR0044-03-03, Contract year: 09/30/20 ? 06/30/22 Contract #90SR0120-01-00, Contract year: 09/30/20 ? 09/29/21 Contract #90SR0120-02-00, Contract year: 09/30/21 ? 09/29/22 Contract #90SR0157-01-01, Contract year: 09/30/21 ? 09/29/22 U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #HHS000539700204 YPI, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPS, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPU, Contract year: 09/01/21 ? 08/31/22 Criteria: Allowable costs ? The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, ?200.430 requires that charges to awards for salaries and wages be based on records that accurately reflect the work performed. These records must: 1) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable and properly allocated; 2) reasonably reflect the total activity for which the employee is compensated; 3) comply with the established accounting policies and practices of the agency; and 4) support the distribution of the employee?s salary or wages among specific activities or cost objectives if the employee works on more than one activity. Without sufficient controls, costs may be inappropriately charged to a federal funding stream. Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain costs are impacted as they are charged to the program based on the direct salary percentages. Cause: Management?s lack of understanding regarding the requirements for charging payroll costs caused improper reporting of time incurred on the federal awards. Effect: Failure to establish controls for adherence with the Uniform Guidance for allowable costs may result in unallowed costs charged to the program. Questioned costs: Unknown Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2022-001 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Direct Federal Funding Continuum of Care Program Assistance Listing #14.267 Contract #TX0392L6E002006, Contract year: 09/01/21 ? 08/31/22 U. S. Department of Health and Human Services Direct Federal Funding Sexual Risk Avoidance Education Assistance Listing #93.060 Contract #90SR0044-03-03, Contract year: 09/30/20 ? 06/30/22 Contract #90SR0120-01-00, Contract year: 09/30/20 ? 09/29/21 Contract #90SR0120-02-00, Contract year: 09/30/21 ? 09/29/22 Contract #90SR0157-01-01, Contract year: 09/30/21 ? 09/29/22 U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #HHS000539700204 YPI, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPS, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPU, Contract year: 09/01/21 ? 08/31/22 Condition and context: Time and effort reporting is based on the amount reflected in the budget rather than actual time spent on the program. Additionally, the allocation of certain costs are impacted as they are charged to the program based on the direct salary percentages. Recommendation: Provide training to ensure that salaries and wages charged to federal programs are supported by personnel activity reports based on actual time worked. Planned corrective action: While the salaries and wages charged to federal programs are supported by a system of internal control which provided a historical and reasonable assurance that the charges are accurate, allowable, properly allocated in a manner which supports the distribution of the employee?s salary or wages among specific activities/programs, and reasonably reflect the total activity for which the employee is compensated, revision to the process will be made to ensure that timesheets will be completed based on actual time worked rather than percentages based on assigned work/time distribution. Actual hours worked will be entered onto timesheets and allocated to applicable grants. As is the current policy, all time submitted by employees will require supervisory approval. Salaries and wages charged to the grant will be based on actual work performed determined by hours submitted by employee and approved by the applicable supervisor. Policies and procedures will be updated to include this required process to ensure that the allocation methodology used to allocate costs between programs reflect the actual relative benefit to the grant. Training will be provided to program and accounting staff to ensure that this process is understood and properly implemented. Responsible officer: Angelica Castillo, CFO Estimated completion date: September 1, 2023

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2022-002
Procurement & Suspension/Debarment

Finding #2022-002 ? Significant Deficiency and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Direct Federal Funding Continuum of Care Program Assistance Listing #14.267 Contract #TX0392L6E002006, Contract year: 09/01/21 ? 08/31/22 U. S. Department of Health and Human Services Direct Federal Funding Sexual Risk Avoidance Education Assistance Listing #93.060 Contract #90SR0044-03-03, Contract year: 09/30/20 ? 06/30/22 Contract #90SR0120-01-00, Contract year: 09/30/20 ? 09/29/21 Contract #90SR0120-02-00, Contract year: 09/30/21 ? 09/29/22 Contract #90SR0157-01-01, Contract year: 09/30/21 ? 09/29/22 U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #HHS000539700204 YPI, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPS, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPU, Contract year: 09/01/21 ? 08/31/22 Criteria: Procurement ? The Uniform Guidance ?200.318 states that nonprofit organizations must: ? Have written procurement procedures that conform to federal and state laws and regulations as identified in the Uniform Guidance, Subtitle III Procurement Standards and other specific contractual requirements. ? Maintain records sufficient to detail the history of procurement decisions. The records must include the rationale for the procurement method, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Condition and context: Change Happens amended its procurement policy in 2022. The policy requires price or rate quotations for annual purchases greater than $15,000 (micro-purchase threshold), which does not comply with the Uniform Guidance micro-purchase threshold of $10,000. The policy also has no provision requiring determination of suspension or debarment of vendors as required by the Uniform Guidance. Cause: The finding occurred as a result of Change Happens adopting a policy that does not fully comply with the provisions of ?200.318 of the Uniform Guidance. Effect: Failure to have a procurement policy that is in accordance with the Uniform Guidance could result in non-compliance and lack of competition in selected vendors. Questioned costs: Unknown Recommendation: Update the procurement policy to be in compliance with the Uniform Guidance with respect to the micro-purchase threshold and suspension/disbarment requirements. Views of responsible officials and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2022-002 ? Significant Deficiency and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Direct Federal Funding Continuum of Care Program Assistance Listing #14.267 Contract #TX0392L6E002006, Contract year: 09/01/21 ? 08/31/22 U. S. Department of Health and Human Services Direct Federal Funding Sexual Risk Avoidance Education Assistance Listing #93.060 Contract #90SR0044-03-03, Contract year: 09/30/20 ? 06/30/22 Contract #90SR0120-01-00, Contract year: 09/30/20 ? 09/29/21 Contract #90SR0120-02-00, Contract year: 09/30/21 ? 09/29/22 Contract #90SR0157-01-01, Contract year: 09/30/21 ? 09/29/22 U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #HHS000539700204 YPI, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPS, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPU, Contract year: 09/01/21 ? 08/31/22 Criteria: Procurement ? The Uniform Guidance ?200.318 states that nonprofit organizations must: ? Have written procurement procedures that conform to federal and state laws and regulations as identified in the Uniform Guidance, Subtitle III Procurement Standards and other specific contractual requirements. ? Maintain records sufficient to detail the history of procurement decisions. The records must include the rationale for the procurement method, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Condition and context: Change Happens amended its procurement policy in 2022. The policy requires price or rate quotations for annual purchases greater than $15,000 (micro-purchase threshold), which does not comply with the Uniform Guidance micro-purchase threshold of $10,000. The policy also has no provision requiring determination of suspension or debarment of vendors as required by the Uniform Guidance. Cause: The finding occurred as a result of Change Happens adopting a policy that does not fully comply with the provisions of ?200.318 of the Uniform Guidance. Effect: Failure to have a procurement policy that is in accordance with the Uniform Guidance could result in non-compliance and lack of competition in selected vendors. Questioned costs: Unknown Recommendation: Update the procurement policy to be in compliance with the Uniform Guidance with respect to the micro-purchase threshold and suspension/disbarment requirements. Views of responsible officials and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2022-002 ? Significant Deficiency and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Direct Federal Funding Continuum of Care Program Assistance Listing #14.267 Contract #TX0392L6E002006, Contract year: 09/01/21 ? 08/31/22 U. S. Department of Health and Human Services Direct Federal Funding Sexual Risk Avoidance Education Assistance Listing #93.060 Contract #90SR0044-03-03, Contract year: 09/30/20 ? 06/30/22 Contract #90SR0120-01-00, Contract year: 09/30/20 ? 09/29/21 Contract #90SR0120-02-00, Contract year: 09/30/21 ? 09/29/22 Contract #90SR0157-01-01, Contract year: 09/30/21 ? 09/29/22 U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #HHS000539700204 YPI, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPS, Contract year: 09/01/21 ? 08/31/22 Contract #HHS000539700204 YPU, Contract year: 09/01/21 ? 08/31/22 Condition and context: Change Happens amended its procurement policy in 2022. The policy requires price or rate quotations for annual purchases greater than $15,000 (micro-purchase threshold), which does not comply with the Uniform Guidance micro-purchase threshold of $10,000. The policy also has no provision requiring determination of suspension or debarment of vendors as required by the Uniform Guidance. Recommendation: Update the procurement policy to be in compliance with the Uniform Guidance with respect to the micro-purchase threshold and suspension/disbarment requirements. Planned corrective action: The procurement policy will be revised to comply with Uniform Guidance and require price or rate quotations for annual purchases greater than $10,000 (micro-purchase threshold). The policy will also be revised to include a provision requiring determination of suspension or debarment of vendors as required by the Uniform Guidance. Responsible officer: Angelica Castillo, CFO Estimated completion date: June 1, 2023

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2022-003
Reporting
REPEAT

Finding #2022-003 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 Criteria: Reporting ? The Federal Funding and Transparency Act (FFATA) requires recipients of non-Recovery Act funded grants and cooperative agreements to report subawards of $30,000 or more. Condition and context: Change Happens did not file the required FFATA reporting for the 7 subawards over $30,000. Repeat of finding #2021-010 for the 2021 major program, Assistance Listing #93.092. Cause: The Corrective Action Plan for finding #2021-010 was not implemented for this program. Effect: Non-compliance with federal reporting requirements. Questioned costs: None Recommendation: Develop a process for FFATA reporting to ensure timely reporting for all federal programs, where applicable, and provide training to personnel regarding FFATA reporting requirements. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2022-003 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 Criteria: Reporting ? The Federal Funding and Transparency Act (FFATA) requires recipients of non-Recovery Act funded grants and cooperative agreements to report subawards of $30,000 or more. Condition and context: Change Happens did not file the required FFATA reporting for the 7 subawards over $30,000. Repeat of finding #2021-010 for the 2021 major program, Assistance Listing #93.092. Cause: The Corrective Action Plan for finding #2021-010 was not implemented for this program. Effect: Non-compliance with federal reporting requirements. Questioned costs: None Recommendation: Develop a process for FFATA reporting to ensure timely reporting for all federal programs, where applicable, and provide training to personnel regarding FFATA reporting requirements. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2022-003 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Direct Federal Funding Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges Assistance Listing #93.332 Contract #NAVCA210403-01-01, Contract year: 08/27/21 ? 08/26/22 Contract #NAVCA210403-02-00, Contract year: 08/27/22 ? 08/26/23 Condition and context: Change Happens did not file the required FFATA reporting for the 7 subawards over $30,000. Recommendation: Develop a process for FFATA reporting to ensure timely reporting for all federal programs, where applicable, and provide training to personnel regarding FFATA reporting requirements. Planned corrective action: A process for FFATA reporting will be finalized to ensure timely reporting of all federal programs. Policies and procedures will be updated to include this required reporting and the associated process. Staff training regarding FFATA reporting requirements will be provided to ensure the process is understood and properly implemented. Responsible officer: Angelica Castillo, CFO Estimated completion date: July 15, 2023

Prior Finding References

2021-010

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FY 2021-08-31

FAC accepted this audit on May 23, 2022 — management decision was due November 23, 2022.

2021-005
Other
REPEAT

Finding #2021-005 ? Significant Deficiency in Cash Disbursements Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse Assistance Listing #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, and HHS000539700052 Contract year: 09/01/20 ? 08/31/21 U. S. Department of Housing and Urban Development Continuum of Care Program Assistance Listing #14.267 Contract #: TX0392L6E001905 Contract year: 09/01/20 ? 08/31/21 Criteria: Financial Management ? The management of Change Happens is responsible for establishing and maintaining an effective system of internal control to ensure adequate segregation of duties is maintained over the cash disbursement process so that authorization, recording, custody of and access to assets, and supervisory reviews be assigned to different individuals. Condition and context: The finding reported as #2021-002 applies to the federal awards. Cause and effect: See finding #2021-002. Repeat of finding #2020-003. Questioned costs: Unknown Recommendation: See finding 2021-002. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2021-005 ? Significant Deficiency in Cash Disbursements Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse Assistance Listing #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, and HHS000539700052 Contract year: 09/01/20 ? 08/31/21 U. S. Department of Housing and Urban Development Continuum of Care Program Assistance Listing #14.267 Contract #: TX0392L6E001905 Contract year: 09/01/20 ? 08/31/21 Criteria: Financial Management ? The management of Change Happens is responsible for establishing and maintaining an effective system of internal control to ensure adequate segregation of duties is maintained over the cash disbursement process so that authorization, recording, custody of and access to assets, and supervisory reviews be assigned to different individuals. Condition and context: The finding reported as #2021-002 applies to the federal awards. Cause and effect: See finding #2021-002. Repeat of finding #2020-003. Questioned costs: Unknown Recommendation: See finding 2021-002. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2021-005 ? Significant Deficiency in Cash Disbursements Condition and context: The finding reported as #2021-002 applies to the federal awards. Recommendation: See finding 2021-002. Planned corrective action: See finding 2021-002. Responsible officer: Angelica Castillo, CFO Estimated completion date: See finding 2021-002.

Prior Finding References

2020-003

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2021-006
Other

Finding #2021-006 ? Significant Deficiency in Government Grant Revenue Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, and HHS000539700052 Contract year: 09/01/20 ? 08/31/21 U. S. Department of Housing and Urban Development Continuum of Care Program Assistance Listing #14.267 Contract #: TX0392L6E001905 Contract year: 09/01/20 ? 08/31/21 Criteria: Financial Management ? The Uniform Guidance ?200.303(a) states that Change Happens must establish and maintain effective internal control over the federal award that provides reasonable assurance that it is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the award. Condition and context: The finding reported as #2021-004 applies to the federal awards. Cause and effect: See finding #2021-004. Questioned costs: Unknown Recommendation: See finding #2021-004. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2021-006 ? Significant Deficiency in Government Grant Revenue Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, and HHS000539700052 Contract year: 09/01/20 ? 08/31/21 U. S. Department of Housing and Urban Development Continuum of Care Program Assistance Listing #14.267 Contract #: TX0392L6E001905 Contract year: 09/01/20 ? 08/31/21 Criteria: Financial Management ? The Uniform Guidance ?200.303(a) states that Change Happens must establish and maintain effective internal control over the federal award that provides reasonable assurance that it is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the award. Condition and context: The finding reported as #2021-004 applies to the federal awards. Cause and effect: See finding #2021-004. Questioned costs: Unknown Recommendation: See finding #2021-004. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2021-006 ? Significant Deficiency in Government Grant Revenue Condition and context: The finding reported as #2021-003 applies to the federal awards. Recommendation: See finding 2021-004. Planned corrective action: See finding 2021-004. Responsible officer: Angelica Castillo, CFO Estimated completion date: See finding 2021-004.

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2021-007
Procurement & Suspension/Debarment
MATERIAL WEAKNESSREPEAT

Finding #2021-007 ? Material Weakness and Other Noncompliance for Assistance Listing #93.092 and #14.267 Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 U. S. Department of Housing and Urban Development Continuum of Care Program Assistance Listing #14.267 Contract #: TX0392L6E001905 Contract year: 09/01/20 ? 08/31/21 Criteria: Procurement ? The Uniform Guidance ?200.318 states that nonprofit organizations must: ? Have written procurement procedures that conform to federal and state laws and regulations as identified in the Uniform Guidance, Subtitle III Procurement Standards and other specific contractual requirements. ? Maintain records sufficient to detail the history of procurement. The records must include the rationale for the procurement method, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Condition and context: We reviewed all fiscal year vendor expenditures and found one annual purchase that exceeded the Uniform Guidance small purchase threshold of $250,000; testing of the expenditure revealed that office rent of approximately $373,000 had not been competitively procured in a manner consistent with the requirements of the Uniform Guidance. Rent reimbursed under Assistance Listing #93.092 related to this contract was $11,456 during the grant period. Rent reimbursed under Assistance Listing #14.267 related to this contract was $13,870 during the grant period. Additionally, in a sample of 15 expenditures greater than $1,000, we found no documentation of performance of procurement procedures in accordance with Change Happens? procurement policy. Repeat of finding #2020-008. Cause: Change Happens? procurement policies make reference to buying from a frequent buyer catalog or using competitive purchasing. The policy states that vendors listed in this catalog are those that the organization has found to have quality products, good pricing, timely delivery and have a good reputation within the community. For all purchases greater than $1,000 that are not in the frequent buyer catalog, three bids must be obtained. There does not appear to be a procurement process to determine which vendors are included in the listing, nor do the vendors appear to be determined from inclusion on a state or local intergovernmental agreement. Effect: Failure to have a procurement policy that is in accordance with the Uniform Guidance and a lack of documented procurement decisions could result in non-compliance and lack of competition in selected vendors. Questioned costs: Unknown Recommendation: Update procurement policy to be in compliance with the Uniform Guidance. Document procurement decisions reflecting the rationale for the method of procurement, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2021-007 ? Material Weakness and Other Noncompliance for Assistance Listing #93.092 and #14.267 Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 U. S. Department of Housing and Urban Development Continuum of Care Program Assistance Listing #14.267 Contract #: TX0392L6E001905 Contract year: 09/01/20 ? 08/31/21 Criteria: Procurement ? The Uniform Guidance ?200.318 states that nonprofit organizations must: ? Have written procurement procedures that conform to federal and state laws and regulations as identified in the Uniform Guidance, Subtitle III Procurement Standards and other specific contractual requirements. ? Maintain records sufficient to detail the history of procurement. The records must include the rationale for the procurement method, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Condition and context: We reviewed all fiscal year vendor expenditures and found one annual purchase that exceeded the Uniform Guidance small purchase threshold of $250,000; testing of the expenditure revealed that office rent of approximately $373,000 had not been competitively procured in a manner consistent with the requirements of the Uniform Guidance. Rent reimbursed under Assistance Listing #93.092 related to this contract was $11,456 during the grant period. Rent reimbursed under Assistance Listing #14.267 related to this contract was $13,870 during the grant period. Additionally, in a sample of 15 expenditures greater than $1,000, we found no documentation of performance of procurement procedures in accordance with Change Happens? procurement policy. Repeat of finding #2020-008. Cause: Change Happens? procurement policies make reference to buying from a frequent buyer catalog or using competitive purchasing. The policy states that vendors listed in this catalog are those that the organization has found to have quality products, good pricing, timely delivery and have a good reputation within the community. For all purchases greater than $1,000 that are not in the frequent buyer catalog, three bids must be obtained. There does not appear to be a procurement process to determine which vendors are included in the listing, nor do the vendors appear to be determined from inclusion on a state or local intergovernmental agreement. Effect: Failure to have a procurement policy that is in accordance with the Uniform Guidance and a lack of documented procurement decisions could result in non-compliance and lack of competition in selected vendors. Questioned costs: Unknown Recommendation: Update procurement policy to be in compliance with the Uniform Guidance. Document procurement decisions reflecting the rationale for the method of procurement, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2021-007 ? Material Weakness and Other Noncompliance for Assistance Listing #93.092 and #14.267 Condition and context: We reviewed all fiscal year vendor expenditures and found one annual purchase that exceeded the Uniform Guidance small purchase threshold of $250,000; testing of the expenditure revealed that office rent of approximately $373,000 had not been competitively procured in a manner consistent with the requirements of the Uniform Guidance. Rent to Assistance Listing #93.092 related to this contract during the grant period was $11,456. Rent to Assistance Listing #14.267 related to this contract during the grant period was $13,870. Additionally, in a sample of 10 expenditures greater than $1,000, we found no documentation of performance of procurement procedures in accordance with Change Happens? procurement policy. Recommendation: Update procurement policy to be in compliance with the Uniform Guidance. Document procurement decisions reflecting the rationale for the method of procurement, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Planned corrective action: Change Happens utilized space at the Elgin Street office owned by Change Happens Community Development Corporation (CHCDC). While the two organizations had no common board members, the Founder and CEO of the Community Development Corporation was also the Founder and CEO of Change Happens until May 2018. The CHCDC charged Change Happens a monthly facility use fee under a prior agreement. In April 2019, CHCDC informed Change Happens that in order to remain in the building, a lease for rental space must be established. Due to the short notification of this requirement and the hardship it would entail to move Change Happens operations, and the lack of rental space in the community in which Change Happens targets its program and services, Change Happens had no recourse than to begin negotiation of a three-year lease agreement which was finalized on August 28, 2019. During the negotiation of the lease agreement, Change Happens utilized an external real estate agency to assist in identifying other available lease property in the proximity of the geographic area needed to provide services in the agency?s target area. A community assessment of the Third Ward community in which Change Happens is located attests to the lack of available space during this period. Therefore, due to the unique circumstances of the situation, that were out of the control of Change Happens, the organization entered into the lease agreement with CHCDC to prevent a disruption of client services. As this was a prior year finding, the procurement policy has been updated as of January 25, 2022 to be in compliance with the Uniform Guidance and requires the rationale for the method of procurement, contractor or vendor selection or rejection, selection of contract type, basis for the contracted price, required documentation, and threshold amount and corresponding approvals required for purchases. Responsible officer: Angelica Castillo, CFO Estimated completion date: January 25, 2022

Prior Finding References

2020-008

About Procurement and Suspension and Debarment →
2021-008
Procurement & Suspension/Debarment
MATERIAL WEAKNESSREPEAT

Finding #2021-008 ? Material Weakness and Material Noncompliance for Assistance Listing #93.959 Applicable federal program: U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, and HHS000539700052 Contract year: 09/01/20 ? 08/31/21 Criteria: See finding #2021-007. Condition and context: See finding #2021-007. The finding reported as #2021-008 is considered material noncompliance for Assistance Listing #93.959 and thus, must be reported separately for purposes of filing with the Federal Audit Clearinghouse. Rent reimbursed under Assistance Listing #93.959 was $158,697 during the grant period. Cause: See finding #2021-007. Effect: See finding #2021-007. Questioned costs: Unknown Recommendation: See finding #2021-007. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2021-008 ? Material Weakness and Material Noncompliance for Assistance Listing #93.959 Applicable federal program: U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, and HHS000539700052 Contract year: 09/01/20 ? 08/31/21 Criteria: See finding #2021-007. Condition and context: See finding #2021-007. The finding reported as #2021-008 is considered material noncompliance for Assistance Listing #93.959 and thus, must be reported separately for purposes of filing with the Federal Audit Clearinghouse. Rent reimbursed under Assistance Listing #93.959 was $158,697 during the grant period. Cause: See finding #2021-007. Effect: See finding #2021-007. Questioned costs: Unknown Recommendation: See finding #2021-007. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2021-008 ? Material Weakness and Material Noncompliance for Assistance Listing #93.959 Condition and context: See finding #2021-007. The finding reported as #2021-008 is considered material noncompliance for Assistance Listing #93.959 and thus, must be reported separately for purposes of filing with the Federal Audit Clearinghouse. Rent reimbursed under Assistance Listing #93.959 was $158,697 during the grant period. Recommendation: See finding #2021-007. Planned corrective action: See finding #2021-007. Responsible officer: Angelica Castillo, CFO Estimated completion date: January 25, 2022

Prior Finding References

2020-008

About Procurement and Suspension and Debarment →
2021-009
Cost Allowability
QUESTIONED COSTS

Finding #2021-009 ? Significant Deficiency and Other Noncompliance Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, and HHS000539700052 Contract year: 09/01/20 ? 08/31/21 U. S. Department of Housing and Urban Development Continuum of Care Program Assistance Listing #14.267 Contract #: TX0392L6E001905 Contract year: 09/01/20 ? 08/31/21 Criteria: Allowable Costs ? Section 200.303 of the Uniform Guidance indicates that the organization must 1) establish and maintain an effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal awards and 2) evaluate and monitor the compliance with statutes, regulations, and terms and conditions of the federal awards. Take prompt action when instances of noncompliance are identified. Condition and context: Change Happens utilizes timesheets and square footage to prepare monthly salary allocations to allocate monthly shared facility allocations to each grant. A sample of 2 monthly facility allocations revealed 1 instance where the amount charged to Assistance Listing #93.959 was not consistent with the hours charged on the timesheet. Cause: The percentages used to prepare the monthly facility allocation journal entry were different from the hours allocated on the timesheet. Journal entry review procedures did not identify the allocation errors. Effect: Failure to appropriately update and review allocation worksheets could result in unallowed costs. Questioned costs: $22 Recommendation: Strengthen journal entry review controls to ensure that percentages used for charges to the grant are supported by the underlying timesheets that match the allocation. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2021-009 ? Significant Deficiency and Other Noncompliance Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, and HHS000539700052 Contract year: 09/01/20 ? 08/31/21 U. S. Department of Housing and Urban Development Continuum of Care Program Assistance Listing #14.267 Contract #: TX0392L6E001905 Contract year: 09/01/20 ? 08/31/21 Criteria: Allowable Costs ? Section 200.303 of the Uniform Guidance indicates that the organization must 1) establish and maintain an effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal awards and 2) evaluate and monitor the compliance with statutes, regulations, and terms and conditions of the federal awards. Take prompt action when instances of noncompliance are identified. Condition and context: Change Happens utilizes timesheets and square footage to prepare monthly salary allocations to allocate monthly shared facility allocations to each grant. A sample of 2 monthly facility allocations revealed 1 instance where the amount charged to Assistance Listing #93.959 was not consistent with the hours charged on the timesheet. Cause: The percentages used to prepare the monthly facility allocation journal entry were different from the hours allocated on the timesheet. Journal entry review procedures did not identify the allocation errors. Effect: Failure to appropriately update and review allocation worksheets could result in unallowed costs. Questioned costs: $22 Recommendation: Strengthen journal entry review controls to ensure that percentages used for charges to the grant are supported by the underlying timesheets that match the allocation. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2021-009 ? Significant Deficiency and Other Noncompliance Condition and context: Change Happens utilizes timesheets and square footage to prepare monthly salary allocations to allocate monthly shared facility allocations to each grant. A sample of 2 monthly facility allocations revealed 1 instance where the amount charged to Assistance Listing #93.959 was not consistent with the hours charged on the timesheet. Recommendation: Strengthen journal entry review controls to ensure that percentages used for charges to the grant are supported by the underlying timesheets that match the allocation. Planned corrective action: The CFO will review and approve the space allocation journal entry for each month. Discrepancies will be researched and corrected in a timely manner. Additionally, a quarterly reconciliation of space allocation journal entries to the applicable timesheets will be performed by accounting personnel. Required adjustments will be reviewed, approved, documented, and posted to the general ledger, as necessary. As this was a prior year finding, accounting policies and procedures have been updated to include the quarterly reconciliation of payroll and space allocation journal entries and processes have been implemented as of January 1, 2022. Responsible officer: Angelica Castillo, CFO Estimated completion date: January 1, 2022

About Allowable Costs / Cost Principles →
2021-010
Reporting

Finding #2021-010 ? Significant Deficiency and Other Noncompliance Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 Criteria: Reporting ? The Federal Funding and Transparency Act (FFATA) requires recipients of non-Recovery Act funded grants and cooperative agreements to report subawards of $25,000 or more. Condition and context: Change Happens did not file the required FFATA reporting for a subaward over $25,000. Cause: Program personnel were not aware of the FFATA reporting requirement. Effect: Non-compliance with federal reporting requirements. Questioned costs: None Recommendation: Provide additional training to personnel to understand FFATA reporting requirements. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2021-010 ? Significant Deficiency and Other Noncompliance Applicable federal programs: U. S. Department of Health and Human Services Affordable Care Act (ACA) Personal Responsibility Education Program Assistance Listing #93.092 Contract #?s: 90AK0051-05-00 and 90AK0051-06-03 Contract years: 09/30/19 ? 09/29/20 and 09/30/20 ? 06/30/22 Criteria: Reporting ? The Federal Funding and Transparency Act (FFATA) requires recipients of non-Recovery Act funded grants and cooperative agreements to report subawards of $25,000 or more. Condition and context: Change Happens did not file the required FFATA reporting for a subaward over $25,000. Cause: Program personnel were not aware of the FFATA reporting requirement. Effect: Non-compliance with federal reporting requirements. Questioned costs: None Recommendation: Provide additional training to personnel to understand FFATA reporting requirements. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2021-010 ? Significant Deficiency and Other Noncompliance Condition and context: Change Happens did not file the required FFATA reporting for a subaward over $25,000. Recommendation: Provide additional training to personnel to understand when FFATA reporting is required. Planned corrective action: Designated staff will enter information on the sub-awardee into the Federal Funding Accountability and Transparency Act (FFATA) Sub-Award Reporting System (FSRS) when a sub-award is issued and executed. Accounting personnel will conduct a regular bi-annual verification to ensure that all sub-awardees are in the FSRS system. The required FFATA will be filed for the subaward over $25,000 applicable to year ending August 31, 2021. Responsible officer: Angelica Castillo, CFO Estimated completion date: May 31, 2022

About Reporting →

FY 2020-08-31

FAC accepted this audit on November 29, 2021 — management decision was due May 29, 2022.

2020-005
Other
MATERIAL WEAKNESSREPEAT

Finding #2020-005 ? Material Weakness in Preparation of the Schedule of Expenditures of Federal Awards (SEFA) This finding impacts all federal awards. Criteria: Management is responsible for establishing and maintaining an effective system of internal control over financial reporting, including preparation of the SEFA. Condition and context: Change Happens? procedures for financial reporting of the SEFA are not sufficient to ensure that errors would be detected and corrected in a timely manner. Audit revisions to the SEFA were required to include expenditures for three new federal grants. Additionally, revisions of approximately $165,000 were required to increase current year expenditures due to errors in reversal of prior year accrued receivables that were never actually submitted for reimbursement. Repeat of finding #2019-002. Cause and effect: Procedures are not sufficient to ensure that the SEFA includes all federal grants and all expenditures. As a result, adjustments were identified to properly report expenditures reported on the SEFA. The failure to adequately establish and maintain effective internal controls over financial reporting resulted in misstatements to Change Happens? SEFA. Recommendation: Policies and procedures should be developed to ensure that all federal expenditures are properly reflected on the SEFA. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2020-005 ? Material Weakness in Preparation of the Schedule of Expenditures of Federal Awards (SEFA) This finding impacts all federal awards. Criteria: Management is responsible for establishing and maintaining an effective system of internal control over financial reporting, including preparation of the SEFA. Condition and context: Change Happens? procedures for financial reporting of the SEFA are not sufficient to ensure that errors would be detected and corrected in a timely manner. Audit revisions to the SEFA were required to include expenditures for three new federal grants. Additionally, revisions of approximately $165,000 were required to increase current year expenditures due to errors in reversal of prior year accrued receivables that were never actually submitted for reimbursement. Repeat of finding #2019-002. Cause and effect: Procedures are not sufficient to ensure that the SEFA includes all federal grants and all expenditures. As a result, adjustments were identified to properly report expenditures reported on the SEFA. The failure to adequately establish and maintain effective internal controls over financial reporting resulted in misstatements to Change Happens? SEFA. Recommendation: Policies and procedures should be developed to ensure that all federal expenditures are properly reflected on the SEFA. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2020-005 ? Material Weakness in Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Condition and context: Change Happens? procedures for financial reporting of the SEFA are not sufficient to ensure that errors would be detected and corrected in a timely manner. Audit revisions to the SEFA were required to include expenditures for three new federal grants. Additionally, revisions of approximately $165,000 were required to increase current year expenditures due to errors in reversal of prior year accrued receivables that were never actually submitted for reimbursement. Repeat of finding #2019-002. Recommendation: Policies and procedures should be developed to ensure that all federal expenditures are properly reflected on the SEFA. Planned corrective action: Accounting policies and procedures will be updated to include a reconciliation process to accurately capture all federal expenditures to be reported on the SEFA. The reconciliation process will validate expenditures on the general ledger match expenditures reflected on the corresponding federal funder reports and disbursements (drawdowns) reflected in the general ledger match disbursements processed per the funder reports. While expenditures and disbursements are validated to funder reports with each drawdown, a formal reconciliation process will be performed on a quarterly basis. Responsible officer: Angelica Castillo, CFO Estimated completion date: December 31, 2021

Prior Finding References

2019-002

About Other →
2020-006
Reporting
MATERIAL WEAKNESS

Finding #2020-006 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 Criteria: Reporting ? Management is responsible for establishing and maintaining an effective system of internal control over government grant reporting to ensure all expenditures are properly stated in the various required grant reports in the correct period and that government grant revenue and receivables are properly reflected in the financial statements. Condition and context: The finding reported as #2020-001 resulted in adjustments to reported grant expenditures for the year ended August 31, 2020. Cause and effect: See finding #2020-001. Questioned costs: None Recommendation: See finding #2020-001. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2020-006 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 Criteria: Reporting ? Management is responsible for establishing and maintaining an effective system of internal control over government grant reporting to ensure all expenditures are properly stated in the various required grant reports in the correct period and that government grant revenue and receivables are properly reflected in the financial statements. Condition and context: The finding reported as #2020-001 resulted in adjustments to reported grant expenditures for the year ended August 31, 2020. Cause and effect: See finding #2020-001. Questioned costs: None Recommendation: See finding #2020-001. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2020-006 ? Material Weakness and Other Noncompliance Condition and context: The finding reported as #2020-001 resulted in adjustments to reported grant expenditures for the year ended August 31, 2020. Recommendation: See finding #2020-001. Planned corrective action: See finding #2020-001. Responsible officer: Angelica Castillo, CFO Estimated completion date: December 31, 2021

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2020-007
Other

Finding #2020-007 ? Significant Deficiency in Cash Disbursements Applicable federal programs: U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 Criteria: Effective internal control requires that certain responsibilities such as authorization of transactions, recording of transactions in the accounting records, custody of and access to assets, and supervisory reviews be assigned to separate individuals. Such duties have not been segregated with respect to vendor cash disbursements and could result in unauthorized disbursements due to fraud or error. Condition and context: The finding reported as #2020-003 applies to the federal awards. Cause and effect: See finding #2020-003. Questioned costs: Unknown Recommendation: See finding 2020-003. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2020-007 ? Significant Deficiency in Cash Disbursements Applicable federal programs: U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 Criteria: Effective internal control requires that certain responsibilities such as authorization of transactions, recording of transactions in the accounting records, custody of and access to assets, and supervisory reviews be assigned to separate individuals. Such duties have not been segregated with respect to vendor cash disbursements and could result in unauthorized disbursements due to fraud or error. Condition and context: The finding reported as #2020-003 applies to the federal awards. Cause and effect: See finding #2020-003. Questioned costs: Unknown Recommendation: See finding 2020-003. Views of responsible officers and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2020-007 ? Material Weakness and Other Noncompliance Condition and context: The finding reported as #2020-003 applies to the federal awards. Recommendation: See finding #2020-003. Planned corrective action: See finding #2020-003. Responsible officer: Angelica Castillo, CFO Estimated completion date: November 30, 2021

About Other →
2020-008
Procurement & Suspension/Debarment
MATERIAL WEAKNESS

Finding #2020-008 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 Criteria: Procurement ? The Uniform Guidance ?200.318 states that nonprofit organizations must: ? Have written procurement procedures that conform to federal and state laws and regulations as identified in the Uniform Guidance, Subtitle III Procurement Standards and other specific contractual requirements. ? Maintain records sufficient to detail the history of procurement. The records must include the rationale for the procurement method, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Condition and context: We reviewed all fiscal year vendor expenditures and found one annual purchase that met the Uniform Guidance small purchase threshold of $250,000; testing of the expenditure revealed that office rent in the amount of approximately $373,000 had not been competitively procured in a manner consistent with the requirements of the Uniform Guidance. Rent to CFDA #93.297 related to this contract during the grant period was $9,518. Rent to CFDA #14.267 related to this contract during the grant period was $12,809. Additionally, in a sample of 15 expenditures greater than $1,000, we found no documentation of performance of procurement procedures in accordance with Change Happens? procurement policy. Cause: Change Happens? procurement policies make reference to buying from a frequent buyer catalog or using competitive purchasing. The policy states that vendors listed in this catalog are those that the organization has found to have quality products, good pricing, timely delivery and have a good reputation within the community. There does not appear to be a procurement process to determine which vendors are included in the listing, nor do the vendors appear to be determined from inclusion on a state or local intergovernmental agreement. For all purchases greater than $1,000 that are not in the frequent buyer catalog, three bids must be obtained. Effect: Failure to have a procurement policy that is in accordance with the Uniform Guidance and a lack of documented procurement decisions could result in non-compliance and lack of competition in selected vendors. Questioned costs: Unknown Recommendation: Update procurement policy to be in compliance with the Uniform Guidance. Document procurement decisions reflecting the rationale for the method of procurement, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Full finding narrative

Finding #2020-008 ? Material Weakness and Other Noncompliance Applicable federal programs: U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 Criteria: Procurement ? The Uniform Guidance ?200.318 states that nonprofit organizations must: ? Have written procurement procedures that conform to federal and state laws and regulations as identified in the Uniform Guidance, Subtitle III Procurement Standards and other specific contractual requirements. ? Maintain records sufficient to detail the history of procurement. The records must include the rationale for the procurement method, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Condition and context: We reviewed all fiscal year vendor expenditures and found one annual purchase that met the Uniform Guidance small purchase threshold of $250,000; testing of the expenditure revealed that office rent in the amount of approximately $373,000 had not been competitively procured in a manner consistent with the requirements of the Uniform Guidance. Rent to CFDA #93.297 related to this contract during the grant period was $9,518. Rent to CFDA #14.267 related to this contract during the grant period was $12,809. Additionally, in a sample of 15 expenditures greater than $1,000, we found no documentation of performance of procurement procedures in accordance with Change Happens? procurement policy. Cause: Change Happens? procurement policies make reference to buying from a frequent buyer catalog or using competitive purchasing. The policy states that vendors listed in this catalog are those that the organization has found to have quality products, good pricing, timely delivery and have a good reputation within the community. There does not appear to be a procurement process to determine which vendors are included in the listing, nor do the vendors appear to be determined from inclusion on a state or local intergovernmental agreement. For all purchases greater than $1,000 that are not in the frequent buyer catalog, three bids must be obtained. Effect: Failure to have a procurement policy that is in accordance with the Uniform Guidance and a lack of documented procurement decisions could result in non-compliance and lack of competition in selected vendors. Questioned costs: Unknown Recommendation: Update procurement policy to be in compliance with the Uniform Guidance. Document procurement decisions reflecting the rationale for the method of procurement, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2020-008 ? Significant Deficiency and Other Noncompliance Condition and context: We reviewed all fiscal year vendor expenditures and found one annual purchase that met the Uniform Guidance small purchase threshold of $250,000; testing of the expenditure revealed that office rent in the amount of approximately $373,000 had not been competitively procured in a manner consistent with the requirements of the Uniform Guidance. Rent to CFDA #93.297 related to this contract during the grant period was $9,518. Rent to CFDA #14.267 related to this contract during the grant period was $12,809. Additionally, in a sample of 15 expenditures greater than $1,000, we found no documentation of performance of procurement procedures in accordance with Change Happens? procurement policy. Recommendation: Update procurement policy to be in compliance with the Uniform Guidance. Document procurement decisions reflecting the rationale for the method of procurement, selection of contract type, contractor or vendor selection or rejection, and the basis for the contracted price. Planned corrective action: Change Happens utilized space without a formal lease agreement at the Elgin Street office owned by Change Happens Community Development Corporation (CHCDC). While the two organizations had no common board members, the Founder and CEO of the Community Development Corporation was also the Founder and CEO of Change Happens until May 2018. In April 2019, CHCDC informed Change Happens that a lease for rental space must be established. Due to the short notification of this requirement, the hardship it would entail to move Change Happens? operations, and the lack of rental space in the Change Happens? community, Change Happens believed it had no recourse than to begin negotiation of a three-year lease agreement, which was finalized on August 28, 2019. During the negotiation of the lease agreement, Change Happens utilized an external real estate agency to assist in identifying other available lease properties in the proximity of the geographic area needed to provide services in the agency?s target area. A community assessment of the Third Ward community in which Change Happens is located attests to the lack of available space during this period. Therefore, due to the unique circumstances which were out of the control of Change Happens, the organization entered into the lease agreement with CHCDC to prevent a disruption of client services. The procurement policy is currently being updated to include the rationale for the method of procurement, contractor or vendor selection or rejection, selection of contract type, basis for the contracted price, required documentation, and threshold amount and corresponding approvals required for purchases. Responsible officer: Angelica Castillo, CFO Estimated completion date: December 31, 2021

About Procurement and Suspension and Debarment →
2020-009
Cost Allowability
QUESTIONED COSTS

Finding #2020-009 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 Criteria: Allowable costs ? Management is responsible for having an internal control system in place to ensure that only allowable costs in accordance with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards ?200.400 are recorded and allocated to federal awards. An effective internal control system includes a review of transactions for verification of accuracy as to amount and period and also requires retention of documentation, supporting the transaction to evidence proper approval, and to provide accurate reporting of transactions. Condition and context: In a sample of 46 vendor expenditures (24 from CFDA #93.297 and 22 from CFDA #93.959 and #93.788), we identified 1 sample unit was recorded as expended based on quotes received from the vendor but never purchased, and 1 sample unit where the amount recorded as expended was based on a quote, but the actual invoice was less than the quote provided. Cause: Expenditures were accrued at year end based on quotes received from vendors instead of actual invoices. In one case, the purchase never occurred and in the other case the invoice paid after year end was less than the quote that was provided and accrued. Effect: Failure to accrue expenditures based on invoices provided resulted in amounts being billed erroneously to the grants. Questioned costs: $3,816 Recommendation: Implement policies and procedures to only accrue as payable those goods and services received and accrue amounts supported by vendor invoices. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2020-009 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 Criteria: Allowable costs ? Management is responsible for having an internal control system in place to ensure that only allowable costs in accordance with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards ?200.400 are recorded and allocated to federal awards. An effective internal control system includes a review of transactions for verification of accuracy as to amount and period and also requires retention of documentation, supporting the transaction to evidence proper approval, and to provide accurate reporting of transactions. Condition and context: In a sample of 46 vendor expenditures (24 from CFDA #93.297 and 22 from CFDA #93.959 and #93.788), we identified 1 sample unit was recorded as expended based on quotes received from the vendor but never purchased, and 1 sample unit where the amount recorded as expended was based on a quote, but the actual invoice was less than the quote provided. Cause: Expenditures were accrued at year end based on quotes received from vendors instead of actual invoices. In one case, the purchase never occurred and in the other case the invoice paid after year end was less than the quote that was provided and accrued. Effect: Failure to accrue expenditures based on invoices provided resulted in amounts being billed erroneously to the grants. Questioned costs: $3,816 Recommendation: Implement policies and procedures to only accrue as payable those goods and services received and accrue amounts supported by vendor invoices. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2020-009 ? Significant Deficiency and Other Noncompliance Condition and context: In a sample of 46 vendor expenditures (24 from CFDA #93.297 and 22 from CFDA #93.959 and #93.788), we identified 1 sample unit was recorded as expended based on quotes received from the vendor but never purchased, and 1 sample unit where the amount recorded as expended was based on a quote, but the actual invoice was less than the quote provided. Recommendation: Implement policies and procedures to only accrue as payable those goods and services received and accrue amounts supported by vendor invoices. Planned corrective action: Purchases will be reviewed on a regular basis and as part of the month-end close checklist. Accrual entries and the supporting documentation will be reviewed and approved by the CFO. Accounting policies and procedures will be revised to include the requirement that only goods and services actually received as supported by a vendor invoice will be accrued. Appropriate steps and measures will be implemented so that accrued expenses are tracked and reviewed monthly to ensure proper treatment based on generally accepted accounting principles. Responsible officer: Angelica Castillo, CFO Estimated completion date: November 30, 2021

About Allowable Costs / Cost Principles →
2020-010
Cost Allowability
QUESTIONED COSTS

Finding #2020-010 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 Criteria: Allowable costs ? Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), ?200.430 requires that charges to awards for salaries and wages be based on records that accurately reflect the work performed. These records must 1) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable and properly allocated; 2) reasonably reflect the total activity for which the employee is compensated; 3) comply with the established accounting policies and practices of the agency; and 4) support the distribution of the employee?s salary or wages among specific activities or cost objectives if the employee works on more than one activity. Change Happens? procedures for allocating costs are not sufficient to ensure that costs are appropriately allocated amongst federal funding streams. Condition and context: Change Happens utilizes timesheets to prepare monthly salary allocations to each grant. A sample of 66 payroll charges to the general ledger revealed 1 instance where the amount charged to CFDA #93.297 was not consistent with the hours charged on the timesheet. Journal entry review procedures are not sufficient to identify allocation errors. Cause: The percentages used to prepare the monthly allocation journal entry were different from the hours allocated on the timesheet. The explanation indicated that there was a change in the individual?s budgeted time that was not reflected on the timesheet and the amount charged to the grant was based on budget instead of actual time spent. Effect: Failure to charge awards for salaries and wages based on records that accurately reflect the work performed could result in unallowed costs. Questioned costs: $41 Recommendation: Strengthen journal entry review controls to ensure that percentages used for charges to the grant are supported by the underlying timesheets that match the allocation and are based on actual time spent. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

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Finding #2020-010 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 Criteria: Allowable costs ? Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), ?200.430 requires that charges to awards for salaries and wages be based on records that accurately reflect the work performed. These records must 1) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable and properly allocated; 2) reasonably reflect the total activity for which the employee is compensated; 3) comply with the established accounting policies and practices of the agency; and 4) support the distribution of the employee?s salary or wages among specific activities or cost objectives if the employee works on more than one activity. Change Happens? procedures for allocating costs are not sufficient to ensure that costs are appropriately allocated amongst federal funding streams. Condition and context: Change Happens utilizes timesheets to prepare monthly salary allocations to each grant. A sample of 66 payroll charges to the general ledger revealed 1 instance where the amount charged to CFDA #93.297 was not consistent with the hours charged on the timesheet. Journal entry review procedures are not sufficient to identify allocation errors. Cause: The percentages used to prepare the monthly allocation journal entry were different from the hours allocated on the timesheet. The explanation indicated that there was a change in the individual?s budgeted time that was not reflected on the timesheet and the amount charged to the grant was based on budget instead of actual time spent. Effect: Failure to charge awards for salaries and wages based on records that accurately reflect the work performed could result in unallowed costs. Questioned costs: $41 Recommendation: Strengthen journal entry review controls to ensure that percentages used for charges to the grant are supported by the underlying timesheets that match the allocation and are based on actual time spent. Views of responsible officers and planned corrective action: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2020-010 ? Significant Deficiency and Other Noncompliance Condition and context: Change Happens utilizes timesheets to prepare monthly salary allocations to each grant. A sample of 66 payroll charges to the general ledger revealed 1 instance where the amount charged to CFDA #93.297 was not consistent with the hours charged on the timesheet. Journal entry review procedures are not sufficient to identify allocation costs. Recommendation: Strengthen journal entry review controls to ensure that percentages used for charges to the grant are supported by the underlying timesheets that match the allocation and are based on actual time spent. Planned corrective action: A monthly reconciliation of payroll allocation journal entries to the applicable timesheets will be added to the month-end closing checklist. Discrepancies will be researched and addressed in a timely manner. Required adjustments will be reviewed, approved, documented, and posted to the general ledger as necessary. Accounting policies and procedures will be updated to include the monthly reconciliation of payroll allocation journal entries. Responsible officer: Angelica Castillo, CFO Estimated completion date: December 31, 2021

About Allowable Costs / Cost Principles →
2020-011
Period of Performance
QUESTIONED COSTS

Finding #2020-011 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 Criteria: Period of Performance ? Uniform Guidance ?200.309 indicates that only allowable costs incurred during the period of performance may be charged to the federal award. Costs incurred before the start date and after the end date of the federal award may not be charged to the award without prior approval. Condition and context: During our testing of 46 federal grant vendor expenditures, we identified 3 expenditures coded to an incorrect period based on when the goods and services were received resulting in charges to the grant outside the contract period. Cause: There is not an effective system of internal controls to ensure that expenses are recorded in the appropriate period. Two of the expenditures were credit card charges that had been incurred in the previous fiscal year, but were not recorded until the following fiscal year when the credit card statement was processed. One expenditure was for equipment purchases that were improperly accrued at the end of the year, but not received or paid until the following fiscal year. Effect: Failure to have effective internal controls over recording expenses to the correct period resulted in costs charged to grants outside of the period of performance. Questioned costs: $3,000 Recommendation: Provide additional training on the review of proper period for recognition of expense transactions. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

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Finding #2020-011 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Housing and Urban Development Continuum of Care Program CFDA #14.267 Contract #: TX0392L6E01804 Contract year: 09/01/19 ? 08/31/20 U. S. Department of Health and Human Services Teenage Pregnancy Prevention Program CFDA #93.297 Contract #?s: 1 TP1AH000187-01-00 and 1 TP1AH000187-02-00 Contract years: 07/01/19 ? 06/30/20 and 07/01/20 ? 06/30/21 U. S. Department of Health and Human Services Passed through Texas Health and Human Services Commission: Block Grants for Prevention & Treatment of Substance Abuse CFDA #93.959 Contract #?s: HHS000539700008, HHS000077600004, HHS000539700103, HHS000539700180, HHS000539700052, and 2016-048205-003 Contract year: 09/01/19 ? 08/31/20 Criteria: Period of Performance ? Uniform Guidance ?200.309 indicates that only allowable costs incurred during the period of performance may be charged to the federal award. Costs incurred before the start date and after the end date of the federal award may not be charged to the award without prior approval. Condition and context: During our testing of 46 federal grant vendor expenditures, we identified 3 expenditures coded to an incorrect period based on when the goods and services were received resulting in charges to the grant outside the contract period. Cause: There is not an effective system of internal controls to ensure that expenses are recorded in the appropriate period. Two of the expenditures were credit card charges that had been incurred in the previous fiscal year, but were not recorded until the following fiscal year when the credit card statement was processed. One expenditure was for equipment purchases that were improperly accrued at the end of the year, but not received or paid until the following fiscal year. Effect: Failure to have effective internal controls over recording expenses to the correct period resulted in costs charged to grants outside of the period of performance. Questioned costs: $3,000 Recommendation: Provide additional training on the review of proper period for recognition of expense transactions. Views of responsible officials and planned corrective actions: Management agrees with the finding. See Corrective Action Plan.

Corrective Action Plan

Finding #2020-011 ? Significant Deficiency and Other Noncompliance Condition and context: During our testing of 46 federal grant vendor expenditures, we identified 3 expenditures coded to an incorrect period based on when the goods and services were received resulting in charges to the grant outside the contract period. Recommendation: Provide additional training on the review of proper period for recognition of expense transactions. Planned corrective action: Expenditures are reviewed by the new CFO for appropriate amounts, dates, proper period recognition, applicable accruals, general ledger coding, program approval, and appropriate grants. Expenditures are approved once all criteria are reviewed and validated. Accounting policies and procedures will be updated to include that all accounting personnel register for and attend mandatory training sessions at a minimum, bi-annually, in various areas of accounting, including proper period of expense recognition. Training sessions will be selected from a variety of sources including training available through federal and state funders, the American Institute of CPAs (AICPA), and external professional development sources. Responsible officer: Angelica Castillo, CFO Estimated completion date: December 31, 2021

About Period of Performance →

FY 2019-08-31

FAC accepted this audit on January 4, 2021 — management decision was due July 4, 2021.

2019-004
Matching, Level of Effort, Earmarking

The Organization did not have proper procedures in place to timely review that matching costs incurred were recorded in the financial statements based on grant requirements. Although the matching requirements had been met based upon timesheets prepared by contract staff, staff and volunteers, the costs were not completely recorded in the financial records. As a result, the Organization?s financial statements did not reflect that the Organization had met the matching requirement required by the grants. In addition, there was no control in place to review budget to actual costs to ensure the earmarking requirement was met. Effect: Without internal controls operating effectively, it is possible that the Organization would be at risk to be out of compliance with the matching and earmarking compliance requirements of the program which could result in return of grant funds or inability to utilize all available grant funding. Cause: Turnover in the Organization?s CFO position caused a lack of proper close-out procedures, including no reconciliation of matching and in-kind expenses between the detail records, financial records and the grants reports being performed. In addition, there were no reconciliations performed during the fiscal year related to this compliance area. Questioned Costs: None. Auditors? Recommendation: The Organization should timely review and reconcile program reports to financial reporting to ensure that matching costs are recorded accurately and timely. Management should review the budget to actual in its financial reporting to ensure that the Organization is in compliance with matching and earmarking requirements. Views of Responsible Officials: The match reporting has been added to the month end checklist as well as the monthly budget summary and is reviewed and approved by the CEO and the CFO in preparation for the monthly budget meetings. The monthly journal entries will be reviewed and approved by the CFO.

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U.S. Department of Housing and Urban Development 14.267 ? Office of Community Planning and Development ? Continuum of Care Program Federal Award: TX0392L6E001703 2018-2019 Funding Criteria: Under 2 CFR Section 200.303(a), non-federal entities must establish and maintain effective internal controls to provide reasonable assurance that the entity is managing the federal awards in compliance with statues, regulations, and the terms and conditions of the award. Additionally, under 24 CFR Section 578.78 and 24 CFR Section 578.59, the Organization must have internal controls to ensure the compliance with matching and earmarking requirements, to ensure that those requirements are met for each grant. Condition: The Organization did not have proper procedures in place to timely review that matching costs incurred were recorded in the financial statements based on grant requirements. Although the matching requirements had been met based upon timesheets prepared by contract staff, staff and volunteers, the costs were not completely recorded in the financial records. As a result, the Organization?s financial statements did not reflect that the Organization had met the matching requirement required by the grants. In addition, there was no control in place to review budget to actual costs to ensure the earmarking requirement was met. Effect: Without internal controls operating effectively, it is possible that the Organization would be at risk to be out of compliance with the matching and earmarking compliance requirements of the program which could result in return of grant funds or inability to utilize all available grant funding. Cause: Turnover in the Organization?s CFO position caused a lack of proper close-out procedures, including no reconciliation of matching and in-kind expenses between the detail records, financial records and the grants reports being performed. In addition, there were no reconciliations performed during the fiscal year related to this compliance area. Questioned Costs: None. Auditors? Recommendation: The Organization should timely review and reconcile program reports to financial reporting to ensure that matching costs are recorded accurately and timely. Management should review the budget to actual in its financial reporting to ensure that the Organization is in compliance with matching and earmarking requirements. Views of Responsible Officials: The match reporting has been added to the month end checklist as well as the monthly budget summary and is reviewed and approved by the CEO and the CFO in preparation for the monthly budget meetings. The monthly journal entries will be reviewed and approved by the CFO.

Corrective Action Plan

2019-004 Internal Controls over Matching and Earmarking (Significant Deficiency) Recommendation: The Organization should timely review and reconcile program reports to financial reporting to ensure that matching costs are recorded accurately and timely. Management should review the budget to actual in its financial reporting to ensure that the Organization is in compliance with matching and earmarking requirements. Corrective Action: The Reporting for Match has been added to the month end check list as well as the Monthly Budget Summary and is reviewed and approved by the CEO and the CFO in preparation for the Monthly Budget Meetings. The monthly journal entries are reviewed and approved by the CFO. Responsible Party: Chief Financial Officer Date Expected to be corrected: August 31, 2020

About Matching, Level of Effort, Earmarking →

FY 2017-08-31

FAC accepted this audit on August 12, 2018 — management decision was due February 12, 2019.

2017-001
Program Income
MATERIAL WEAKNESS

GSA_MIGRATION

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GSA_MIGRATION

Corrective Action Plan

GSA_MIGRATION

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2017-003
Program Income
MATERIAL WEAKNESS

GSA_MIGRATION

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GSA_MIGRATION

Corrective Action Plan

GSA_MIGRATION

About Program Income →
2017-004
Program Income
QUESTIONED COSTS

GSA_MIGRATION

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GSA_MIGRATION

Corrective Action Plan

GSA_MIGRATION

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