Audit 363792

FINDING 2023-002 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listings Number: 21.027 Federal Award Number and Year (or Other Identifying Number): 400ARPHLTHISSCH Pass-Through Entity: Indiana Department of Health Compliance Requirement: Reporting Audit Findings: Significant Deficiency, Other Matters Repeat Finding This is a similar finding from the immediately prior audit report. The prior audit finding number was 2022-004. Condition and Context The County Health Department (Health Department) was awarded the Health Issues and Challenges Grant through the Indiana Department of Health (IDOH), financed through the COVID-19 - Coronavirus State and Local Fiscal Recovery Funds. The grant was funded through the American Rescue Plan Act that focused on the improvement of chronic disease and, more specifically, elevated blood lead level reduction. INDIANA STATE BOARD OF ACCOUNTS 17 ELKHART COUNTY SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Monthly Reimbursement Submissions The Health Department was required to submit data through the online portal, the National Electronic Disease Surveillance System (NEDSS) Base System (NBS), each month. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels (EBLLs). A Case Manager managed all aspects of an individual patient's care. A home visit and two assessments were completed by the Case Manager and input into the NBS. Once these steps were marked as complete in the NBS, the Clinical Manager reviewed each case and compiled data along with the cost reimbursement amount into a spreadsheet. The Clinical Manager provided the spreadsheet to the Manager of Administration who then completed and submitted the reimbursement invoice to the IDOH. The reimbursement invoice was submitted without a documented oversight, review, or approval process to ensure the accuracy of the data prior to submission. Data and Health Equity Report Beginning in October 2022, the Health Department was required to submit program specific metrics and work plan data through the RedCap software on a quarterly basis. The Case Manager was responsible for tracking and compiling the necessary information for the quarterly reports. Of the four reports tested, two reports were submitted late. In addition, the quarterly reports were submitted by the Case Manager via the RedCap software without a documented oversight, review, or approval process to ensure timely submission. The lack of internal controls was a systemic issue throughout the audit period. Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). . . ." 2 CFR 200.329(c)(1) states in part: "The non-Federal entity must submit performance reports at the interval required by the Federal awarding agency or pass-through entity to best inform improvements in program outcomes and productivity. Intervals must be no less frequent than annually nor more frequent than quarterly except in unusual circumstances, for example where more frequent reporting is necessary for the effective monitoring of the Federal award or could significantly affect program outcomes. Reports submitted annually by the non-Federal entity and/or pass-through entity must be due no later than 90 calendar days after the reporting period. Reports submitted quarterly or semiannually must be due no later than 30 calendar days after the reporting period . . ." INDIANA STATE BOARD OF ACCOUNTS 18 ELKHART COUNTY SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Cause The issues with the reimbursement submissions and Data and Health Equity reporting processes stem from the lack of a formal oversight and review procedure to ensure accuracy and timeliness. Without a structured verification process before submission, potential errors and inconsistencies could go undetected, thus increasing the likelihood of inaccurate data reporting. Additionally, the reliance on individual staff members to compile and submit reports without secondary review created inefficiencies and contributed to delays, as evidenced by the late submission of two quarterly reports. Effect The lack of oversight and review of the reimbursement submissions and Data and Health Equity reporting process could result in increased risk of inaccurate data being reported to the IDOH, which could compromise the integrity of the program's performance metrics. The absence of a structed verification process can also lead to inefficiencies, as error or inconsistencies may have required corrections after submission, resulting in inefficient use of time and resources. Additionally, the late submission of two quarterly reports indicated a failure to meet reporting deadlines, which could negatively impact compliance with grant requirements and potentially jeopardize future funding opportunities. Questioned Costs There were no questioned costs identified. Recommendation We recommended the Health Department implement a formal oversight and review process for all data submissions to ensure accuracy and completeness before they are submitted to the IDOH. This would involve a secondary review by a designated individual or team to verify the data. Additionally, improving workflow coordination through clearly defined roles and responsibilities for each team member would help streamline the process and prevent delays. To further improve timeliness, the Health Department should implement a tracking and reminder system for report due dates and reimbursement deadlines to ensure timely submissions. Providing staff with thorough training on reporting protocols and maintaining detailed documentation will help ensure consistent adherence to procedures. Finally, establishing accountability measures through clear roles, deadlines, and regular audits would enhance the efficiency and effectiveness of the reporting process. These steps will help ensure the Health Department meets grant requirements, maintains data accuracy, and avoids potential delays or issues in future submissions. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.

FINDING 2023-002 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listings Number: 21.027 Federal Award Number and Year (or Other Identifying Number): 400ARPHLTHISSCH Pass-Through Entity: Indiana Department of Health Compliance Requirement: Reporting Audit Findings: Significant Deficiency, Other Matters Repeat Finding This is a similar finding from the immediately prior audit report. The prior audit finding number was 2022-004. Condition and Context The County Health Department (Health Department) was awarded the Health Issues and Challenges Grant through the Indiana Department of Health (IDOH), financed through the COVID-19 - Coronavirus State and Local Fiscal Recovery Funds. The grant was funded through the American Rescue Plan Act that focused on the improvement of chronic disease and, more specifically, elevated blood lead level reduction. INDIANA STATE BOARD OF ACCOUNTS 17 ELKHART COUNTY SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Monthly Reimbursement Submissions The Health Department was required to submit data through the online portal, the National Electronic Disease Surveillance System (NEDSS) Base System (NBS), each month. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels (EBLLs). A Case Manager managed all aspects of an individual patient's care. A home visit and two assessments were completed by the Case Manager and input into the NBS. Once these steps were marked as complete in the NBS, the Clinical Manager reviewed each case and compiled data along with the cost reimbursement amount into a spreadsheet. The Clinical Manager provided the spreadsheet to the Manager of Administration who then completed and submitted the reimbursement invoice to the IDOH. The reimbursement invoice was submitted without a documented oversight, review, or approval process to ensure the accuracy of the data prior to submission. Data and Health Equity Report Beginning in October 2022, the Health Department was required to submit program specific metrics and work plan data through the RedCap software on a quarterly basis. The Case Manager was responsible for tracking and compiling the necessary information for the quarterly reports. Of the four reports tested, two reports were submitted late. In addition, the quarterly reports were submitted by the Case Manager via the RedCap software without a documented oversight, review, or approval process to ensure timely submission. The lack of internal controls was a systemic issue throughout the audit period. Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). . . ." 2 CFR 200.329(c)(1) states in part: "The non-Federal entity must submit performance reports at the interval required by the Federal awarding agency or pass-through entity to best inform improvements in program outcomes and productivity. Intervals must be no less frequent than annually nor more frequent than quarterly except in unusual circumstances, for example where more frequent reporting is necessary for the effective monitoring of the Federal award or could significantly affect program outcomes. Reports submitted annually by the non-Federal entity and/or pass-through entity must be due no later than 90 calendar days after the reporting period. Reports submitted quarterly or semiannually must be due no later than 30 calendar days after the reporting period . . ." INDIANA STATE BOARD OF ACCOUNTS 18 ELKHART COUNTY SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Cause The issues with the reimbursement submissions and Data and Health Equity reporting processes stem from the lack of a formal oversight and review procedure to ensure accuracy and timeliness. Without a structured verification process before submission, potential errors and inconsistencies could go undetected, thus increasing the likelihood of inaccurate data reporting. Additionally, the reliance on individual staff members to compile and submit reports without secondary review created inefficiencies and contributed to delays, as evidenced by the late submission of two quarterly reports. Effect The lack of oversight and review of the reimbursement submissions and Data and Health Equity reporting process could result in increased risk of inaccurate data being reported to the IDOH, which could compromise the integrity of the program's performance metrics. The absence of a structed verification process can also lead to inefficiencies, as error or inconsistencies may have required corrections after submission, resulting in inefficient use of time and resources. Additionally, the late submission of two quarterly reports indicated a failure to meet reporting deadlines, which could negatively impact compliance with grant requirements and potentially jeopardize future funding opportunities. Questioned Costs There were no questioned costs identified. Recommendation We recommended the Health Department implement a formal oversight and review process for all data submissions to ensure accuracy and completeness before they are submitted to the IDOH. This would involve a secondary review by a designated individual or team to verify the data. Additionally, improving workflow coordination through clearly defined roles and responsibilities for each team member would help streamline the process and prevent delays. To further improve timeliness, the Health Department should implement a tracking and reminder system for report due dates and reimbursement deadlines to ensure timely submissions. Providing staff with thorough training on reporting protocols and maintaining detailed documentation will help ensure consistent adherence to procedures. Finally, establishing accountability measures through clear roles, deadlines, and regular audits would enhance the efficiency and effectiveness of the reporting process. These steps will help ensure the Health Department meets grant requirements, maintains data accuracy, and avoids potential delays or issues in future submissions. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.