Views from Responsible Officials and Corrective Action Plan BCFS Health and Human Services For the Year Ended August 31, 2025 Finding Number: 2025‑001 and 2025-002Federal Program: Crime Victim Assistance – AL 16.575 (Common Thread – Texas) Pass‑Through Entity: Texas Office of the Governor Award Numb...
Views from Responsible Officials and Corrective Action Plan BCFS Health and Human Services For the Year Ended August 31, 2025 Finding Number: 2025‑001 and 2025-002Federal Program: Crime Victim Assistance – AL 16.575 (Common Thread – Texas) Pass‑Through Entity: Texas Office of the Governor Award Number: 3853406 Questioned Costs: $853,982 Responsible Person: Rosa Baez, President BCFS Health and Human Services Views of Responsible Officials: Management concurs with the finding. BCFS Health and Human Services’ (BCFS HHS) in-kind match plan includes the use of exempt personnel performing after-hours "on-call" volunteer duties, such as answering phones or undertaking responsibilities outside their standard work roles. BCFS HHS did not meet the in-kind match requirements, as the former Program Executive Director deviated from the in-kind match plan, as approved by the funder. The former Program Executive Director did so by hiring full-time personnel to perform the same duties as the on-call volunteers and including them as part of the in-kind match. In 2022, during the COVID pandemic, the funder waived match requirements; during this period, the prior Program Executive Director hired full-time overnight on-call personnel, in response to increased call volume driven by restrictions on face-to-face services due to concerns of exposure. The match waiver was discontinued with the grant awarded for October 2024 through September 2025, and BCFS HHS was required to meet their match obligations. The former Program Executive Director failed to reassign the On-Call workers resulting in a significant deviation from the approved match plan and contributed to the noncompliance of in-kind match requirements. Immediately upon the issuance of the monitoring report regarding match requirements, BCFS HHS’ President has been actively working with Office of the Governor (OOG) to rectify the match requirements per the grant. Management has recorded an accrual for the estimated adjustment and has implemented the corrective action plan outlined below. Page 2 of 3 Corrective Action Plan Upon receiving the preliminary monitoring report from the OOG, management promptly initiated an internal review with the OOG and began collaborating with OOG to address and resolve the findings identified. Effective immediately, BCFS HHS has established new protocols to ensure compliance with match requirements for the Common Thread Texas program. BCFS HHS will undertake the following corrective actions: 1. Revised In-Kind Volunteer Hotline Process A protocol has been implemented to manage the volunteer hotline for the Common Thread Program during after-hour operations. The hotline provides callers with program information, resources, referrals, and transfers calls as appropriate, including crisis response or intake services. The volunteer hotline is managed by volunteers that include exempt employees (working outside their regular duties), interns, and other approved community volunteers. Volunteers must complete training prior to being scheduled. The protocol guidelines include: •A designated volunteer timesheet. •A signed attestation certifying that hours listed are an accurate record ofvolunteer service. •Confirmation that the volunteer work is not required by their employment andis different and separate from their regular job duties. These measures provide robust supporting documentation and ensure that match activities are voluntary, allowable, and compliant. The Volunteer Hotline Protocol was reviewed and approved by the Office of the Governor (Public Safety Office and Office of Compliance and Monitoring). Target completion: Completed January 2026 2. Strengthen Match Documentation Processes Volunteer Attestation and Timesheet- Volunteers are required to sign a timesheet and an attestation affirming that the recorded hours accurately reflect their service with the Common Thread Volunteer Hotline. Additionally, if applicable, volunteers must confirm that this service is not mandated by their employment and is distinct from their regular job responsibilities. Monthly Match Meetings: These meetings will review the reported match activities against the approved match plan. Additionally, the meetings provide an opportunity to evaluate current needs and trends, and to ensure match obligations are met. Page 3 of 3 Target completion: Completed January 2026. 3. Correct and Reclassify Previously Reported Match BCFS HHS excluded the disallowed match activities and included permissible methods such as unrecovered indirect costs, reductions in billed expenditures, including personnel and training—and additional adjustments approved by OOG. All necessary changes are incorporated in the final Financial Status Report (FSR) submitted on January 29, 2026. Target completion: Completed. 4. Staff Training and Ongoing Compliance Monitoring BCFS HHS will provide Common Thread leadership training on uniform guidance match requirements, OOG-specific guidance, and the Volunteer Hotline Protocols. Weekly Audits- The BCFS HHS Director of Support Services, or designee, will conduct weekly audits to ensure protocol adherence. This will encompass a review of the hotline volunteers’ timesheets, and schedules. Results will be discussed in the monthly match meetings. Use of U.S. Bureau of Labor Statistics wage data- All volunteer and intern hours are valued using OOG‑approved labor categories. Target completion: Training will be completed by February 28, 2026; monitoring process will be implemented February 1, 2026. Sincerely, Rosa Baez, President BCFS Health and Human Services