Finding 1175005 (2025-002)

Material Weakness Repeat Finding
Requirement
G
Questioned Costs
-
Year
2025
Accepted
2026-02-23
Audit: 388639
Organization: Bcfs Health and Human Services (TX)
Auditor: FORVIS MAZARS

AI Summary

  • Core Issue: BCFS HHS did not meet matching requirements for federal assistance, leading to an overstated match of approximately $850,000.
  • Impacted Requirements: Violations of 2 CFR regulations on cost sharing, financial records, and documentation standards, as well as Texas OOG program guidance.
  • Recommended Follow-Up: Implement a compliant on-call policy, re-evaluate in-kind hours, remove unallowable match, and enhance internal controls over timekeeping and reporting.

Finding Text

U.S. Department of Justice/Passed-Through Texas Office of the Governor Crime Victim Assistance Federal Assistance Listing Number: 16.575 – Common Thread - Texas Award Number: 3853406 Award Year: September 1, 2024 – October 31, 2025 Criteria or Specific Requirement: Matching – Under 2 CFR § 200.306, cost sharing/matching must be allowable, verifiable, properly valued, within the period of performance, and adequately documented. 2 CFR § 200.302 requires accurate, current, complete financial records. 2 CFR § 200.430 requires records that support compensation and time worked. Texas Office of the Governor's (OOG) program guidance further requires set rates, timekeeping, and preconditions when employee on‑call is used as in‑kind (not the same or similar duties; voluntary participation). Condition: BCFS HHS did not comply with matching requirements. Reported match included (1) unpaid employee on‑call hours without required timekeeping and (2) over‑valued volunteer/intern hours, including some ineligible activities. Subsequent discussions with OOG indicate approximately $850,000 of match is unallowable and will require correction through repayments and/or budget reductions. Cause: The prior program executive director deviated from using the in-kind match plan that had been previously approved by the public safety officer (PSO) – utilizing exempt personnel; taking “on-call” (answering phones) after hours, performing duties different from their normal work duties, could be considered as volunteer hours and count towards in-kind match. During 2022 (COVID-19 pandemic), PSO waived match requirements, the program executive director hired overnight on-call workers, believed to be due to increase in call volume. Following the pandemic, the PSO discontinued the match wavier in October 2024. The program executive director failed to reassign the on-call workers, resulting in a compromise of the in-kind match plan. BCFS HHS’ documentation and valuation practices in place during the period were not fully aligned with the specific documentation, rate‑setting, and classification requirements outlined in Office of the Governor’s (OOG) monitoring guidance. Effect or Potential Effect: Reported match was overstated, requiring budget and reporting corrections in the E-grants system, and may result in repayment or additional local match to cure the deficit. Questioned Costs: $853,982. Calculated from OOG’s identification of disallowed/questioned match related to on‑call, volunteer, and intern match; and BCFS HHS’ internal calculation of anticipated corrections, including indirect cost adjustments and the expected reclassification of mileage and training amounts. Context: Match claimed on FSRs for period 10/1/2024–8/31/2025 under Grant 3853406; OOG review covered 10/1/2024–2/28/2025 with extrapolation through August for cash match. Repeat Finding: None. Recommendation: We recommend BCFS HHS 1) Implement a board‑approved on‑call policy that complies with OOG and Uniform Guidance; 2) Re‑value all in‑kind hours using approved rates; 3) Remove or reclassify any unallowable match; 4) Obtain pass‑through approval for unrecovered indirect used as match; and 5) Strengthen internal controls over timekeeping, valuation, and reporting. Views of Responsible Officials and Corrective Action: Management concurs with the finding and is working with the OOG on an approved remediation plan that includes application of unrecovered indirect, and reduction of other allowable costs to cure the match deficit. See further information on the corrective action plan provided by management.

Corrective Action Plan

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

Categories

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring Eligibility Period of Performance Reporting

Other Findings in this Audit

  • 1175000 2025-002
    Material Weakness Repeat
  • 1175001 2025-002
    Material Weakness Repeat
  • 1175002 2025-002
    Material Weakness Repeat
  • 1175003 2025-002
    Material Weakness Repeat
  • 1175004 2025-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.556 MARYLEE ALLEN PROMOTING SAFE AND STABLE FAMILIES PROGRAM $1.58M
93.086 HEALTHY MARRIAGE PROMOTION AND RESPONSIBLE FATHERHOOD GRANTS $1.35M
93.926 HEALTHY START INITIATIVE $1.01M
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $373,705
93.434 EVERY STUDENT SUCCEEDS ACT/PRESCHOOL DEVELOPMENT GRANTS $360,000
93.590 COMMUNITY-BASED CHILD ABUSE PREVENTION GRANTS $300,000
16.575 CRIME VICTIM ASSISTANCE $281,728
93.671 FAMILY VIOLENCE PREVENTION AND SERVICES/DOMESTIC VIOLENCE SHELTER AND SUPPORTIVE SERVICES $274,904
93.550 TRANSITIONAL LIVING FOR HOMELESS YOUTH $204,770
16.726 JUVENILE MENTORING PROGRAM $134,401
93.558 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES $126,873
16.320 SERVICES FOR TRAFFICKING VICTIMS $86,859
93.566 REFUGEE AND ENTRANT ASSISTANCE STATE/REPLACEMENT DESIGNEE ADMINISTERED PROGRAMS $82,250
93.912 RURAL HEALTH CARE SERVICES OUTREACH, RURAL HEALTH NETWORK DEVELOPMENT AND SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT $8,129