CORRECTIVE ACTION PLAN
October 23, 2023
Health Resources and Services Administration
Care Resource Community Health Centers, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023.
____________________________________________________________________________...
CORRECTIVE ACTION PLAN
October 23, 2023
Health Resources and Services Administration
Care Resource Community Health Centers, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023.
____________________________________________________________________________________
CohnReznick LLP
1301 Avenue of the Americas
New York, NY 10019
Audit Period: June 30, 2023
The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule.
FINDINGS – FEDERAL AWARDS PROGRAM AUDIT
U.S. Department of Health and Human Services, Opioid STR (Assistance Listing Number 93.788)
Finding 2023-001 – Reporting
SIGNIFICANT DEFICIENCY
We recommend that the Center strengthen their system of internal controls to ensure that all reporting requirements are monitored and met on a timely basis.
Action Taken
Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency. This deficiency has been corrected as of the current date.
During the fiscal year, there was a data element change in the Carisk portal that required an “evaluation score” to be added to the performance outcome measures. This was not previously required. Although data was uploaded on a monthly basis to the Carisk portal, the change caused the data to be rejected as an “error” resulting in measures not being uploaded. This was discovered in the BBHC February 2023 desk review of July - December 2022 data. A corrective action plan was recommended, prepared, and accepted by BBHC. The “evaluation score” was not part of the template in the electronic medical record (NextGen) therefore data could not be uploaded and was rejected. Once discovered, the data element was added to the template within the electronic medical record and data uploads of performance outcome measures were able to be extracted and successfully uploaded to the Carisk portal.
The screening tool to produce the “evaluation score” is being added to the electronic health record and will be included in the workflow of the Behavioral Health Providers so that it may be captured for performance outcomes and discharges. This process requires the Care Resource Data Analytics team and external data consultants and service providers to create the templates.
During the fiscal year, invoices are due on the 10th of the month unless the tenth falls on a weekend or a holiday in which case the invoices are due the following business day. There are times where extensions are necessary due to portal uploads or data corrections. Approval is given by the contract manager of BBHC. Approvals have been granted verbally and in writing (email). In the case of the invoice for the month of May 2023, verbal approval was provided, however not documented. In the future, all requests if approved verbally, will be confirmed in writing (email) to ensure proper supporting documentation of the approval.
If the Health Resources and Services Administration has questions regarding this plan, please call Keenan Karwan, Chief Financial Officer at 305 - 576-1234 x203.
Sincerely yours,
Keenan Karwan