CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Identifying Number: Finding 2025-001 Identification of federal program: Federal Award Agency: Substance Abuse and Mental Health Services Administration Program Name and Federal Assistance Listing No.: Certified Community Behavioral Health Clinic Expans...
CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Identifying Number: Finding 2025-001 Identification of federal program: Federal Award Agency: Substance Abuse and Mental Health Services Administration Program Name and Federal Assistance Listing No.: Certified Community Behavioral Health Clinic Expansion Grants – 93.696 Pass-Through Entity: not applicable, direct funding Pass-Through Award Numbers: not applicable, direct funding Criteria or specific requirement: Section 200.308 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) governs the revision of program plans. A recipient must request prior written approval from the federal agency entity when there is a disengagement from a project for more than three months, or a 25% reduction in time and effort devoted to the federal award. The terms and conditions of this award require that an evaluator be assigned to the program maintaining a 50% level of effort. Any changes to key personnel including level of effort involving separation from the project for any continuous period of three months or longer, or a reduction in time dedicated to the project of 25% or more requires prior approval and must be submitted as a postaward amendment in eRA Commons. Condition: The Certified Community Behavioral Health Clinic Expansion Grants require that a project evaluator devote 50% level of effort requirement to the program. During the fiscal year ended June 30, 2025, due to program personnel turnover, OhioGuidestone was not able to ensure that the required level of effort be maintained and did not obtain the required approvals maintained by the terms and conditions of the grant agreement. Cause: Due to program personnel turnover, OhioGuidestone was not able to ensure that the required level of effort was maintained for the fiscal year ended June 30, 2025. Effect or potential effect: A failure to comply with the terms and conditions of the grant agreement could result in material noncompliance. Questioned cost: None.Context: Due to staff turnover, the project evaluator position for the Four County grant was vacant during February and March 2025. To maintain continuity, the Organization temporarily assigned the project evaluator from the Cuyahoga County contract to cover these months because of her familiarity with the program. However, prior written approval for this change was not obtained as required by the grant agreement. A new project evaluator was hired for April through June 2025, but onboarding delays prevented full engagement until after year-end. As a result, the level-of-effort requirement was not met for February through June 2025. Recommendation: We recommend that the Organization review existing policies and procedures and make enhancements where appropriate to monitor compliance with level-of-effort requirements on a periodic basis and to ensure that the required approvals are obtained. Corrective Actions Taken or Planned: OhioGuidestone acknowledges and agrees with this finding. In addition to tracking the LOE on the shared monthly budget tracking report, we will include a copy of the NOA Special Terms for Key Personnel in the report. If the LOE falls below the required level, the Grant Manager will inform Program Leadership using the comments section of the shared workbook. The staff assigned to the comment will respond with reasoning and expected timeframe to have the position back up to the required LOE. We will evaluate the situation including timeframe and determine if prior approval and a post award amendment is necessary. In the case of staff termination, we will initiate the post award amendment, notify SAMHSA of the separation, and seek approval to deviate from the required LOE during the recruiting period. Upon hiring for the position, another post award amendment will be submitted notifying SAMHSA of the new staff. Grant Manager will host a meeting with all staff involved detailing the new process. Name of contact person responsible for corrective action: Joseph Ziegler, Chief Financial Officer Anticipated completion date: December 31, 2025