LEGACY COMMUNITY HEALTH SERVICES INC

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 Ap…

Corrective action: The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to personnel costs for certain employees being allocated based on a budgeted full-time equivalent basis without subsequent reconciliation to time and effort records. Legacy did not have a time and effort certification process established until recently. All costs have been determined as allowable costs, and the finding is a result of administrative challenges. Steps have already been taken to remedy the issue. In July 2025, the Organization implemented a risk-based attestation process to capture time allocation across grant programs. Following this, The Director of Grant Accounting and Dire…

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 minim…

Corrective action: The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to a lack of verification of whether the patient had active eligibility or not. Steps have been implemented to remedy the issue in FY 2026. The Director of Financial Services-IAT reporting team is enhancing training and communication to improve understanding of eligibility and documentation requirements. Furthermore, procedures will be implemented to systematically monitor all medications billed to Ryan White and State HIV Services Programs, as well as verify participants' current eligibility status on a biweekly basis. The organization expects these processes to run efficiently by April 30t…

HIV Emergency Relief Projects Grants – Assistance Listing No. 93.914 U.S. Department of Health and Human Services Harris County Health Department March 1, 2023 – February 29, 2024 and March 1, 2024 – February 28, 2025 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, 2023 – March 31, 2024 and April 1, 2024 – March 31, 2025 State HIV Services Grant Programs Texas Department of State Health Services Houston Regional HIV/AIDS Resource Group, Inc. September 1, 2022 – August 31, 2023, September 1, 2023 – August 31, 2024, and April 1, 2023 – August 31, 2023 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 principles requirements. Cause - The cost allocation plan d…

Corrective action: The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to personnel costs for certain employees being allocated based on a budgeted full-time equivalent basis without subsequent reconciliation to time and effort records. All costs have been determined as allowable costs, and the finding is a result of administrative challenges. Steps have already been taken to begin addressing the issue. Grant Accounting and Human Resources will implement a time and effort certification process signed by employee and supervisor. This new process will be rolled out during the first quarter of Fiscal Year 2026 with training provided to relevant personnel. The indi…

HIV Emergency Relief Projects Grants – Assistance Listing No. 93.914 U.S. Department of Health and Human Services Harris County Health Department March 1, 2023 – February 29, 2024 and March 1, 2024 – February 28, 2025 Criteria or specific requirement – Eligibility Condition – Program benefits were extended to individuals residing outside the designated service area or for whom eligibility was expired. Cause – The Organization relies on its practice management systems to conduct a portion of the eligibility screening required for this program. During the fiscal year, a new practice management system was purchased and 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 documentati…

Corrective action: The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to a lack of verification of whether the patient had active eligibility or not. Steps have already been taken to begin addressing the issue. Additional training and communication will be provided to the Financial Services team to reinforce understanding of eligibility and documentation requirements. Also, the Data Analyst in the Financial Services team will generate a bi-weekly report in Pioneer to identify all medications being billed to Ryan White and current status of eligibility. Implementation of this planned corrective action is the responsibility of Financial Services-IAT reporting.