Audit 402453

U.S. Department of Health and Human Services 93.958 – Block Grants for Community Mental Health Services Reporting – Significant Deficiency – Internal Control and Compliance Finding 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 noncompliance. Effect: The Organization was unaware of reporting requirements and was not in compliance with the contract. Repeat: Repeat of finding 2023-009. Recommendation: RBT recommends that the Organization review grant contracts prior to signing in order to understand reporting requirements, including what is required to be submitted and the respective due dates. Management Response: See Corrective Action Plan.

Controls Over Federal Programs U.S. Department of Health and Human Services 93.958 – Block Grants for Community Mental Health Services Activities Allowed/Allowable Costs – Significant Deficiency – Internal Control Finding Conditions: The Organization did not have adequate controls over the reporting or expending of Federal Funds. 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: 60 out of 60 selections for testing did not have documented control procedures. Payroll expenses did not tie to distribution reports, there was no documented review of payroll throughout the year, and large reallocations were made after year end based on estimated time and effort to programs. No documentation was maintained for the rationale of these reallocations other than approval by CEO. Invoices were not coded and there was no documentation of review of allocations to Federal Award Programs. 3 of 60 selections tested did not have underlying support. Cause: The Organization did not follow control procedures routinely and has not adopted sufficient relevant controls over the accounting of Federal Expenditures. Effect: Expenses may not be allocated correctly, and payroll expenses were required to be allocated across multiple programs after year end. Repeat: Repeat finding of 2023-007. Recommendation: RBT recommends that the Organization require support for all expenses coded to Federal Awards to be reviewed for proper allocation, period of performance and allowability of the expense. RBT also recommends that payroll allocations are reviewed regularly and updated in the payroll system and the accounting system. Payroll allocations should be based on actual hours worked or documented time studies. Documentation of review and approvals of these control procedures should be maintained on file. Management Response: See Corrective Action Plan.

2024-012 Controls Over Reporting for SMT Program U.S. Department of Health and Human Services 93.958 – Block Grants for Community Mental Health Services Reporting – Significant Deficiency – Internal Control Finding Conditions: The Organization does not have adequate controls in place over reporting requirements. Criteria: Per the Westchester County contract, the Organization is required to keep individual records of program participants available for audit by the County. Context: 3 out of 4 participants selected had instances of encounter notes entered months after the original encounter. 1 of 4 participants was not active in the program and had not been removed from the participant listing. For monthly reporting, reports were submitted but no documentation of review or timely reporting was maintained. Cause: The Organization did not follow control procedures routinely and has not adopted sufficient relevant controls over the records for the program. Effect: Encounter notes may be inaccurate or not complete if audited by the State or HHS. Recommendation: RBT recommends that the Organization establish a system of internal control over records for the program to ensure notes are entered and reviewed timely and that inactive participants are indicated as such. Monthly reports should be documented as reviewed and noted when submitted. Management Response: See Corrective Action Plan.