Audit 384790

FY End
2025-06-30
Total Expended
$21.64M
Findings
24
Programs
10
Year: 2025 Accepted: 2026-01-31

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
1171826 2025-001 Material Weakness Yes B
1171827 2025-001 Material Weakness Yes B
1171828 2025-001 Material Weakness Yes B
1171829 2025-001 Material Weakness Yes B
1171830 2025-001 Material Weakness Yes B
1171831 2025-001 Material Weakness Yes B
1171832 2025-001 Material Weakness Yes B
1171833 2025-001 Material Weakness Yes B
1171834 2025-001 Material Weakness Yes B
1171835 2025-001 Material Weakness Yes B
1171836 2025-001 Material Weakness Yes B
1171837 2025-001 Material Weakness Yes B
1171838 2025-001 Material Weakness Yes B
1171839 2025-001 Material Weakness Yes B
1171840 2025-001 Material Weakness Yes B
1171841 2025-001 Material Weakness Yes B
1171842 2025-001 Material Weakness Yes B
1171843 2025-001 Material Weakness Yes B
1171844 2025-001 Material Weakness Yes B
1171845 2025-001 Material Weakness Yes B
1171846 2025-001 Material Weakness Yes B
1171847 2025-002 Material Weakness Yes E
1171848 2025-002 Material Weakness Yes E
1171849 2025-002 Material Weakness Yes E

Contacts

Name Title Type
HFQGQ4MNA2L4 Rebekah Le Auditee
8325485000 Jansen Otterness Auditor
No contacts on file

Notes to SEFA

The accompanying schedules of expenditures of federal and state awards (the “Schedules”) includes the federal and state award activity of Legacy Community Health Services, Inc. under programs of the federal and state governments for the year ended June 30, 2025. The information in this Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and Texas Grant Management Standards (TxGMS). Because the Schedule presents only a selected portion of the operations of Legacy Community Health Services, Inc., it is not intended to and does not present the financial position, results of operations, changes in net assets, or cash flows of Legacy Community Health Services, Inc.
Legacy Community Health Services, Inc. did not have any federal or state award loan programs during the year ended June 30, 2025.

Finding Details

HIV Emergency Relief Projects Grants – Assistance Listing No. 93.914 U.S. Department of Health and Human Services Harris County Health Department March 1, 2024 – February 29, 2025 and March 1, 2025 – February 28, 2026 HIV Care Formula Grants – Assistance Listing No. 93.917 U.S. Department of Health and Human Services Houston Regional HIV/AIDS Resource Group, Inc. April 1, 2024 – March 31, 2025 and April 1, 2025 – March 31, 2026 Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services H80: May 1, 2024 – April 30,2025 and May 1, 2025 – April 30, 2026 H8K: September 1, 2023 – August 31, 2024 H8L: September 1, 2023 – December 31, 2024 H8N: September 1, 2024 – August 31, 2025 H2E: May 1, 2023 – August 31, 2024 Family Planning Services – Assistance Listing No. 93.217 U.S. Department of Health and Human Services EveryBody Texas April 1, 2024 – March 31, 2025 and April 1, 2025 – March 31, 2026 State HIV Services Grant Programs Texas Department of State Health Services Houston Regional HIV/AIDS Resource Group, Inc. September 1, 2023 – August 31, 2024, and September 1, 2024 – August 31, 2025 Criteria or specific requirement – Allowable Costs and Cost Principles (45 CFR 75.430) and TxGMS Condition - The Organization did not comply with federal and state cost principle requirements. Cause - The cost allocation plan used by the organization distributed costs to multiple federal and state programs using a budgeted full time equivalent (FTE) basis without subsequent reconciliation to actual time and effort records. Effect or potential effect - Amounts charged to Assistance Listing Numbers 93.914, 93.917, 93.224, 93.527, 93.217, and the Texas State HIV Service Grants were not supported by complete time and effort records. Questioned costs – ALN 93.914 HIV Emergency Relief Projects Grants - $1,571,196; ALN 93.917 HIV Care Formula Grants - $125,729; ALN 93.224 and 93.527 - Health Center Program Cluster $145,203; ALN 93.217 Family Planning Services - $202,495; State HIV Services Grant Programs - $124,550. Questioned costs were quantified using amounts allocated to multiple programs through the Organization's cost allocation plan. Context – Expenditures from each major program were tested. Indirect costs that were allocated across multiple programs were based on budgeted FTE data rather than actual time and effort reports. These indirect costs were identified as errors and represent questions costs of: • HIV Emergency Relief Project Grants – $1,571,196 • HIV Care Formula Grants – $125,729 • Health Center Program Cluster – $145,203 • Family Planning Services Grants – $202,495 • State HIV Services Grant Programs – $124,550 As a result, the Organization was unable to demonstrate compliance with federal cost principles requirements. The sampling methodology is not and is not intended to be statistically valid. Identification as a repeat finding, if applicable – Yes, see 2024-002. Recommendation – The Organization should develop a process to support the time and effort used as a basis of allocation for programmatic expenditures.
HIV Care Formula Grants - Assistance Listing No. 93.917 U.S. Department of Health and Human Services Houston Regional HIV/AIDS Resource Group, Inc. April 1, 2024 - March 31, 2025 and April 1, 2025 - March 31, 2026 State HIV Services Grant Programs Texas Department of State Health Services Houston Regional HIV/AIDS Resource Group, Inc. September 1, 2023 – August 31, 2024, and September 1, 2024 – August 31, 2025 Criteria or specific requirement – Eligibility Condition – Program benefits were extended to individuals for whom eligibility supporting documentation was not available. Cause – The Organization relies on its practice management systems to conduct a portion of the eligibility screening required for these programs. During the prior fiscal year, a new practice management system was implemented. During this time, the Organization provided training and support in an effort to minimize disruption following this change. However, some new processes appear to have not been followed as the Organization transitioned to the new system and some documentation was noted to be missing or not obtained for transactions occurring during the fiscal year. Effect or potential effect – Weaknesses in internal control over compliance present the potential for noncompliance with federal and state eligibility requirements. As a result, program benefits were provided to an individual that did not meet the eligibility requirements of the State HIV Services Grant Programs. Questioned costs – State HIV Services Grant Programs - $779; Questioned costs were quantified using the value of benefits provided to program participants that were not eligible to receive benefits from the program. Context – The Organization's controls to ensure compliance with eligibility requirements are not consistently operating as designed for the impacted programs. In addition, a sample of 25 transactions were tested from a population of approximately 5,075 State HIV Services Grant Programs transactions, with 1 instance of benefits being received by an individual that did not qualify to receive such benefits. The sampling methodology is not and is not intended to be statistically valid. Identification as a repeat finding, if applicable – Yes, see 2024-003 Recommendation – The Organization should review the eligibility policy and procedures to ensure compliance with the ALN 93.917 HIV Care Formula Grants and Texas Department of State Health Services State HIV Services Manuals and other authoritative guidance while considering improvements that can be made for both potential program beneficiaries and personnel. Continued education efforts and internal audit processes should continue as well.