Audit 316636

2023-006 Preparation of Schedule of Expenditures of Federal Awards Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Material Weakness Condition: The Organization was unable to provide a complete Schedule of Expenditures of Federal Awards ("SEFA") with all Federal programs, Assistance Listing Numbers, and total expenditures. Criteria: The Organization is required to track and report Federal Awards and related expenditures in a SEFA in order to comply with Single Audit Requirements. Context: The Organization did not identify several contracts that included Federal Awards and amounts originally reported were for total revenues received and not for expenditures. Cause: The Organization does not have any controls in place to track awards based on funder. The Organization also tracks administrative costs charged to Federal Awards in a separate cost center and does not reconcile indirect costs charged to federal awards with actual indirect expenses incurred. Effect: The Organization may understate expenditures of Federal Awards or deem a Single Audit unnecessary due to improper tracking of awards and expenditures. There was no system in place to track federal awards. Recommendation: RBT recommends that the Organization track revenue and expenditures for federal awards when they are received and spent in order to properly record them on the SEFA.

2023-006 Preparation of Schedule of Expenditures of Federal Awards Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Material Weakness Condition: The Organization was unable to provide a complete Schedule of Expenditures of Federal Awards ("SEFA") with all Federal programs, Assistance Listing Numbers, and total expenditures. Criteria: The Organization is required to track and report Federal Awards and related expenditures in a SEFA in order to comply with Single Audit Requirements. Context: The Organization did not identify several contracts that included Federal Awards and amounts originally reported were for total revenues received and not for expenditures. Cause: The Organization does not have any controls in place to track awards based on funder. The Organization also tracks administrative costs charged to Federal Awards in a separate cost center and does not reconcile indirect costs charged to federal awards with actual indirect expenses incurred. Effect: The Organization may understate expenditures of Federal Awards or deem a Single Audit unnecessary due to improper tracking of awards and expenditures. There was no system in place to track federal awards. Recommendation: RBT recommends that the Organization track revenue and expenditures for federal awards when they are received and spent in order to properly record them on the SEFA.

2023-006 Preparation of Schedule of Expenditures of Federal Awards Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Material Weakness Condition: The Organization was unable to provide a complete Schedule of Expenditures of Federal Awards ("SEFA") with all Federal programs, Assistance Listing Numbers, and total expenditures. Criteria: The Organization is required to track and report Federal Awards and related expenditures in a SEFA in order to comply with Single Audit Requirements. Context: The Organization did not identify several contracts that included Federal Awards and amounts originally reported were for total revenues received and not for expenditures. Cause: The Organization does not have any controls in place to track awards based on funder. The Organization also tracks administrative costs charged to Federal Awards in a separate cost center and does not reconcile indirect costs charged to federal awards with actual indirect expenses incurred. Effect: The Organization may understate expenditures of Federal Awards or deem a Single Audit unnecessary due to improper tracking of awards and expenditures. There was no system in place to track federal awards. Recommendation: RBT recommends that the Organization track revenue and expenditures for federal awards when they are received and spent in order to properly record them on the SEFA.

2023-007 Controls over Records Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Reporting Significant Deficiency Condition: The Organization did not keep individual records of program participants. Criteria: Per the Westchester County contract, the Organization is required to keep individual records of program participants available for audit by the county. Context: Two out of five participants selected for testing had encounter notes updated one to six months after the date of service. The participant list provided for audit included inactive clients and clients that did not enter the program until after year end. Cause: There is no review or noted controls over the records maintained for the program. Effect: The Organization does not have updated records for individuals in the program. Recommendation: RBT recommends developing a review process to confirm encounter notes are added in a timely manner and participants no longer enrolled in the program are inactivated. Additionally, the program should maintain current participant listings.

2023-008 Period of Performance Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Period of Performance Material Weakness Condition: The Organization submitted expenses that were outside of the period of performance per the Westchester County SMT Grant and was unable to provide proof of extension of the NYS Office of Mental Health (OMH) Vaccine Education Block Grant until after testing was completed. Criteria: Per the Westchester County SMT Grant, the period of performance ended on September 30, 2023. Context: For the Westchester County SMT Grant, expenses that related to the period before September 30, 2023 were submitted under the subsequent contract. Although there was a new contract with a period of performance from October 1, 2023 to September 30, 2024, expenses related to the original contract should not have been submitted under the new contract. All expenses related to the original contract period should have been submitted under the original contract. For the OMH Vaccine Education Block Grant, the period of performance ended on July 31, 2023 and no contract extension was maintained on file. Cause: The Organization was unaware that expenses related to the period before September 30, 2023 were submitted under the new Westchester County SMT Grant. The Organization could not confirm the period of performance for the Vaccine Education Block Grant. Effect: The Organization was not in compliance with period of performance requirements for the Westchester County SMT Grant. Recommendation: RBT recommends that the Organization review grant contracts to identify the period of performance and institute controls to ensure all expenses are submitted in the proper period and to the proper contract.

2023-008 Period of Performance Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Period of Performance Material Weakness Condition: The Organization submitted expenses that were outside of the period of performance per the Westchester County SMT Grant and was unable to provide proof of extension of the NYS Office of Mental Health (OMH) Vaccine Education Block Grant until after testing was completed. Criteria: Per the Westchester County SMT Grant, the period of performance ended on September 30, 2023. Context: For the Westchester County SMT Grant, expenses that related to the period before September 30, 2023 were submitted under the subsequent contract. Although there was a new contract with a period of performance from October 1, 2023 to September 30, 2024, expenses related to the original contract should not have been submitted under the new contract. All expenses related to the original contract period should have been submitted under the original contract. For the OMH Vaccine Education Block Grant, the period of performance ended on July 31, 2023 and no contract extension was maintained on file. Cause: The Organization was unaware that expenses related to the period before September 30, 2023 were submitted under the new Westchester County SMT Grant. The Organization could not confirm the period of performance for the Vaccine Education Block Grant. Effect: The Organization was not in compliance with period of performance requirements for the Westchester County SMT Grant. Recommendation: RBT recommends that the Organization review grant contracts to identify the period of performance and institute controls to ensure all expenses are submitted in the proper period and to the proper contract.

2023-008 Period of Performance Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Period of Performance Material Weakness Condition: The Organization submitted expenses that were outside of the period of performance per the Westchester County SMT Grant and was unable to provide proof of extension of the NYS Office of Mental Health (OMH) Vaccine Education Block Grant until after testing was completed. Criteria: Per the Westchester County SMT Grant, the period of performance ended on September 30, 2023. Context: For the Westchester County SMT Grant, expenses that related to the period before September 30, 2023 were submitted under the subsequent contract. Although there was a new contract with a period of performance from October 1, 2023 to September 30, 2024, expenses related to the original contract should not have been submitted under the new contract. All expenses related to the original contract period should have been submitted under the original contract. For the OMH Vaccine Education Block Grant, the period of performance ended on July 31, 2023 and no contract extension was maintained on file. Cause: The Organization was unaware that expenses related to the period before September 30, 2023 were submitted under the new Westchester County SMT Grant. The Organization could not confirm the period of performance for the Vaccine Education Block Grant. Effect: The Organization was not in compliance with period of performance requirements for the Westchester County SMT Grant. Recommendation: RBT recommends that the Organization review grant contracts to identify the period of performance and institute controls to ensure all expenses are submitted in the proper period and to the proper contract.

2023-009 Vaccine Education Grant Reporting Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Reporting Significant Deficiency Condition: The Organization was not in compliance with reporting requirements for the Vaccine Education Block Grant. Criteria: Per the grant contract with NYS Office of Mental Health (OMH), the Organization was required to submit on a quarterly basis a detailed report analyzing the quantitative aspects of the program plan, as appropriate, and a narrative summarizing the services rendered during the quarter. Context: The Organization received email notifications from OMH that they did not submit the required quarterly reports for this grant. Cause: Controls are not designed effectively to prevent or detect errors, misstatements, or non-compliance. Effect: The Organization was unaware of reporting requirements and was not in compliance with the contract. Recommendation: RBT recommends that the Organization review grant contracts when they are signed in order to understand reporting requirements, including what is required to be submitted and the due dates of reports.

2023-010 Controls Over Expenses Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Allowable Cost Principles Significant Deficiency Condition: Expenses related to federal expenditures were not approved. Criteria: Per the Organization’s fiscal policies, purchase orders/credit card payments or cash payment forms are signed by supervisor and CFO noting approval of expenses. Payroll registers are signed as reviewed and approved by CFO. Context: Six out of sixty expenses tested related to the Community Block Grant for WFMT had no approval noted. Twelve out of thirteen payroll registers tested were reprinted and signatures were back dated during fieldwork. Two out of nineteen expenses related to the Community Block Grant for Vaccine Education did not have approvals. Cause: An effective system of internal control has not been designed or implemented. Effect: Expenses and payroll were not documented as reviewed and approved. Recommendation: RBT recommends updating fiscal policies and procedures to reflect current procedures and reviewing controls to ensure they provide assurance that expenses are recorded timely, accurately, and allocated appropriately. Documentation of approvals should be maintained.

2023-010 Controls Over Expenses Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Allowable Cost Principles Significant Deficiency Condition: Expenses related to federal expenditures were not approved. Criteria: Per the Organization’s fiscal policies, purchase orders/credit card payments or cash payment forms are signed by supervisor and CFO noting approval of expenses. Payroll registers are signed as reviewed and approved by CFO. Context: Six out of sixty expenses tested related to the Community Block Grant for WFMT had no approval noted. Twelve out of thirteen payroll registers tested were reprinted and signatures were back dated during fieldwork. Two out of nineteen expenses related to the Community Block Grant for Vaccine Education did not have approvals. Cause: An effective system of internal control has not been designed or implemented. Effect: Expenses and payroll were not documented as reviewed and approved. Recommendation: RBT recommends updating fiscal policies and procedures to reflect current procedures and reviewing controls to ensure they provide assurance that expenses are recorded timely, accurately, and allocated appropriately. Documentation of approvals should be maintained.

2023-006 Preparation of Schedule of Expenditures of Federal Awards Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Material Weakness Condition: The Organization was unable to provide a complete Schedule of Expenditures of Federal Awards ("SEFA") with all Federal programs, Assistance Listing Numbers, and total expenditures. Criteria: The Organization is required to track and report Federal Awards and related expenditures in a SEFA in order to comply with Single Audit Requirements. Context: The Organization did not identify several contracts that included Federal Awards and amounts originally reported were for total revenues received and not for expenditures. Cause: The Organization does not have any controls in place to track awards based on funder. The Organization also tracks administrative costs charged to Federal Awards in a separate cost center and does not reconcile indirect costs charged to federal awards with actual indirect expenses incurred. Effect: The Organization may understate expenditures of Federal Awards or deem a Single Audit unnecessary due to improper tracking of awards and expenditures. There was no system in place to track federal awards. Recommendation: RBT recommends that the Organization track revenue and expenditures for federal awards when they are received and spent in order to properly record them on the SEFA.

2023-006 Preparation of Schedule of Expenditures of Federal Awards Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Material Weakness Condition: The Organization was unable to provide a complete Schedule of Expenditures of Federal Awards ("SEFA") with all Federal programs, Assistance Listing Numbers, and total expenditures. Criteria: The Organization is required to track and report Federal Awards and related expenditures in a SEFA in order to comply with Single Audit Requirements. Context: The Organization did not identify several contracts that included Federal Awards and amounts originally reported were for total revenues received and not for expenditures. Cause: The Organization does not have any controls in place to track awards based on funder. The Organization also tracks administrative costs charged to Federal Awards in a separate cost center and does not reconcile indirect costs charged to federal awards with actual indirect expenses incurred. Effect: The Organization may understate expenditures of Federal Awards or deem a Single Audit unnecessary due to improper tracking of awards and expenditures. There was no system in place to track federal awards. Recommendation: RBT recommends that the Organization track revenue and expenditures for federal awards when they are received and spent in order to properly record them on the SEFA.

2023-006 Preparation of Schedule of Expenditures of Federal Awards Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Material Weakness Condition: The Organization was unable to provide a complete Schedule of Expenditures of Federal Awards ("SEFA") with all Federal programs, Assistance Listing Numbers, and total expenditures. Criteria: The Organization is required to track and report Federal Awards and related expenditures in a SEFA in order to comply with Single Audit Requirements. Context: The Organization did not identify several contracts that included Federal Awards and amounts originally reported were for total revenues received and not for expenditures. Cause: The Organization does not have any controls in place to track awards based on funder. The Organization also tracks administrative costs charged to Federal Awards in a separate cost center and does not reconcile indirect costs charged to federal awards with actual indirect expenses incurred. Effect: The Organization may understate expenditures of Federal Awards or deem a Single Audit unnecessary due to improper tracking of awards and expenditures. There was no system in place to track federal awards. Recommendation: RBT recommends that the Organization track revenue and expenditures for federal awards when they are received and spent in order to properly record them on the SEFA.

2023-007 Controls over Records Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Reporting Significant Deficiency Condition: The Organization did not keep individual records of program participants. Criteria: Per the Westchester County contract, the Organization is required to keep individual records of program participants available for audit by the county. Context: Two out of five participants selected for testing had encounter notes updated one to six months after the date of service. The participant list provided for audit included inactive clients and clients that did not enter the program until after year end. Cause: There is no review or noted controls over the records maintained for the program. Effect: The Organization does not have updated records for individuals in the program. Recommendation: RBT recommends developing a review process to confirm encounter notes are added in a timely manner and participants no longer enrolled in the program are inactivated. Additionally, the program should maintain current participant listings.

2023-008 Period of Performance Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Period of Performance Material Weakness Condition: The Organization submitted expenses that were outside of the period of performance per the Westchester County SMT Grant and was unable to provide proof of extension of the NYS Office of Mental Health (OMH) Vaccine Education Block Grant until after testing was completed. Criteria: Per the Westchester County SMT Grant, the period of performance ended on September 30, 2023. Context: For the Westchester County SMT Grant, expenses that related to the period before September 30, 2023 were submitted under the subsequent contract. Although there was a new contract with a period of performance from October 1, 2023 to September 30, 2024, expenses related to the original contract should not have been submitted under the new contract. All expenses related to the original contract period should have been submitted under the original contract. For the OMH Vaccine Education Block Grant, the period of performance ended on July 31, 2023 and no contract extension was maintained on file. Cause: The Organization was unaware that expenses related to the period before September 30, 2023 were submitted under the new Westchester County SMT Grant. The Organization could not confirm the period of performance for the Vaccine Education Block Grant. Effect: The Organization was not in compliance with period of performance requirements for the Westchester County SMT Grant. Recommendation: RBT recommends that the Organization review grant contracts to identify the period of performance and institute controls to ensure all expenses are submitted in the proper period and to the proper contract.

2023-008 Period of Performance Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Period of Performance Material Weakness Condition: The Organization submitted expenses that were outside of the period of performance per the Westchester County SMT Grant and was unable to provide proof of extension of the NYS Office of Mental Health (OMH) Vaccine Education Block Grant until after testing was completed. Criteria: Per the Westchester County SMT Grant, the period of performance ended on September 30, 2023. Context: For the Westchester County SMT Grant, expenses that related to the period before September 30, 2023 were submitted under the subsequent contract. Although there was a new contract with a period of performance from October 1, 2023 to September 30, 2024, expenses related to the original contract should not have been submitted under the new contract. All expenses related to the original contract period should have been submitted under the original contract. For the OMH Vaccine Education Block Grant, the period of performance ended on July 31, 2023 and no contract extension was maintained on file. Cause: The Organization was unaware that expenses related to the period before September 30, 2023 were submitted under the new Westchester County SMT Grant. The Organization could not confirm the period of performance for the Vaccine Education Block Grant. Effect: The Organization was not in compliance with period of performance requirements for the Westchester County SMT Grant. Recommendation: RBT recommends that the Organization review grant contracts to identify the period of performance and institute controls to ensure all expenses are submitted in the proper period and to the proper contract.

2023-008 Period of Performance Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Period of Performance Material Weakness Condition: The Organization submitted expenses that were outside of the period of performance per the Westchester County SMT Grant and was unable to provide proof of extension of the NYS Office of Mental Health (OMH) Vaccine Education Block Grant until after testing was completed. Criteria: Per the Westchester County SMT Grant, the period of performance ended on September 30, 2023. Context: For the Westchester County SMT Grant, expenses that related to the period before September 30, 2023 were submitted under the subsequent contract. Although there was a new contract with a period of performance from October 1, 2023 to September 30, 2024, expenses related to the original contract should not have been submitted under the new contract. All expenses related to the original contract period should have been submitted under the original contract. For the OMH Vaccine Education Block Grant, the period of performance ended on July 31, 2023 and no contract extension was maintained on file. Cause: The Organization was unaware that expenses related to the period before September 30, 2023 were submitted under the new Westchester County SMT Grant. The Organization could not confirm the period of performance for the Vaccine Education Block Grant. Effect: The Organization was not in compliance with period of performance requirements for the Westchester County SMT Grant. Recommendation: RBT recommends that the Organization review grant contracts to identify the period of performance and institute controls to ensure all expenses are submitted in the proper period and to the proper contract.

2023-009 Vaccine Education Grant Reporting Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Reporting Significant Deficiency Condition: The Organization was not in compliance with reporting requirements for the Vaccine Education Block Grant. Criteria: Per the grant contract with NYS Office of Mental Health (OMH), the Organization was required to submit on a quarterly basis a detailed report analyzing the quantitative aspects of the program plan, as appropriate, and a narrative summarizing the services rendered during the quarter. Context: The Organization received email notifications from OMH that they did not submit the required quarterly reports for this grant. Cause: Controls are not designed effectively to prevent or detect errors, misstatements, or non-compliance. Effect: The Organization was unaware of reporting requirements and was not in compliance with the contract. Recommendation: RBT recommends that the Organization review grant contracts when they are signed in order to understand reporting requirements, including what is required to be submitted and the due dates of reports.

2023-010 Controls Over Expenses Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Allowable Cost Principles Significant Deficiency Condition: Expenses related to federal expenditures were not approved. Criteria: Per the Organization’s fiscal policies, purchase orders/credit card payments or cash payment forms are signed by supervisor and CFO noting approval of expenses. Payroll registers are signed as reviewed and approved by CFO. Context: Six out of sixty expenses tested related to the Community Block Grant for WFMT had no approval noted. Twelve out of thirteen payroll registers tested were reprinted and signatures were back dated during fieldwork. Two out of nineteen expenses related to the Community Block Grant for Vaccine Education did not have approvals. Cause: An effective system of internal control has not been designed or implemented. Effect: Expenses and payroll were not documented as reviewed and approved. Recommendation: RBT recommends updating fiscal policies and procedures to reflect current procedures and reviewing controls to ensure they provide assurance that expenses are recorded timely, accurately, and allocated appropriately. Documentation of approvals should be maintained.

2023-010 Controls Over Expenses Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Allowable Cost Principles Significant Deficiency Condition: Expenses related to federal expenditures were not approved. Criteria: Per the Organization’s fiscal policies, purchase orders/credit card payments or cash payment forms are signed by supervisor and CFO noting approval of expenses. Payroll registers are signed as reviewed and approved by CFO. Context: Six out of sixty expenses tested related to the Community Block Grant for WFMT had no approval noted. Twelve out of thirteen payroll registers tested were reprinted and signatures were back dated during fieldwork. Two out of nineteen expenses related to the Community Block Grant for Vaccine Education did not have approvals. Cause: An effective system of internal control has not been designed or implemented. Effect: Expenses and payroll were not documented as reviewed and approved. Recommendation: RBT recommends updating fiscal policies and procedures to reflect current procedures and reviewing controls to ensure they provide assurance that expenses are recorded timely, accurately, and allocated appropriately. Documentation of approvals should be maintained.