FINDING 2023-002
Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting
Federal Agency: Department of the Treasury
Summary of Finding: (copied from SBOA Findings document provided)
The Allen County Department of Health (Department of Health), a department within
Allen County,...
FINDING 2023-002
Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting
Federal Agency: Department of the Treasury
Summary of Finding: (copied from SBOA Findings document provided)
The Allen County Department of Health (Department of Health), a department within
Allen County, was awarded the Health Issues and Challenges grant through the Indiana
Department of Health financed through the American Rescue Plan Act (ARPA) for the
purposes of funding programs that focus on the improvement of chronic disease,
specifically, elevated blood lead level reduction.
As part of sound management of the Federal award, the Department of Health was
responsible for implementing a system of internal control that would ensure compliance
with the applicable requirements. The Department of Health did not properly design or
implement such a system.
The Department of Health was required to submit data through the online portal,
National Electronic Disease Surveillance System (NEDSS) Base System (NBS),
monthly beginning in October 2022. The submitted data included program specific
metrics relating to patient case management of certified Elevated Blood Lead Levels
(EBLLs). The Department of Health was also required to ensure environmental
investigation activities completed, including risk assessments and environmental
inspections, were documented in the Indiana I-LEAD database monthly by a licensed
Lead Risk Assessor.
Environmental investigation activities performed by the Department of Health were
documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who
was an employee of the Department of Health. Similarly, case management activities
performed were documented in the NEDSS Base System (NBS). Once activities were
documented in the I-LEAD and NBS systems, the activities were further documented in
a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case
Management Coordinator (for NBS activities). The spreadsheet was reviewed by the
Director of the Environmental Services Division and the Finance Director monthly. The
Finance Director then used the spreadsheet to prepare the monthly reimbursement
requests and sent the monthly reimbursement requests to the Indiana
Department of Health. We determined through inquiry with the Director of the
Environmental Services Division and the Finance Director that while there was a review
of the monthly spreadsheet, there was not a second review of the spreadsheet back to
the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance
Director prepared and submitted the reimbursement requests to the State without a
second review or oversight process in place to prevent, or detect and correct, errors
prior to submission.
The lack of internal controls was a systemic issue throughout the audit period.
Recommendation
We recommend that management of the Health Department design and implement a
proper system of internal controls, including policies and procedures that would provide
segregation of duties to ensure appropriate reviews, approvals, and oversight are taking
place to ensure reports are complete and accurate.
…………………………
Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance
Director)
Contact Phone Number and Email Address: 260-449-7358
(Jennifer.miller@allencounty.us)
Views of Responsible Officials:
We concur with the finding
Explanation and Reasons for Disagreement:
N/A
Description of Corrective Action Plan:
We were unaware of a requirement for a secondary review of each
document/spreadsheet/database input/task that was conducted prior to submission
to the Finance Director (defining the completed cases for which to invoice the State),
and a requirement for a secondary review of the invoice/billing documents prior to
submission to the State. We were informed that the State review process (as was
described to SBOA staff) was the check and balance needed which ensured we had
appropriately entered the data into the required database(s) and that we had then
subsequently billed for those very same appropriately completed and entered cases.
However, when we were informed of the outcomes of the SBOA audit and the
subsequent need for a corrective action plan (CAP) relative to their findings, we
moved quickly to begin the development of the CAP -- as we do now understand
that despite the inaccurate instructions we were given, we did not appropriately do
what the law requires locally relative to ensuring accurate completion of duties under
grant contracts before submission for reimbursement.
THE PLAN (which will be added as a new “Grants” section in our existing Finance
Internal Controls policies):
For all grants (reimbursable or deliverables-based), once a contract is near
completion or upon execution, a primary and secondary staff member will be
identified for each step of the database entry (as an example, and this will
follow whatever the duties are defined by the grant and a primary responsible
staff member will be defined per grant duty needs) as well as for the
invoicing/billing documentation process. The primary staff member(s) will be
responsible for doing what is defined in the grant contract (a duty, task, data
entry, invoice creation, etc.) and the secondary staff member will be
responsible for verifying the work of the primary staff member(s). (In some
cases, when there are diverse duties and more than one primary staff member
is needed to do the duties of the grant, there may be several primary staff
members assigned to various duties as needed)
If disparities are encountered (such as errors or omissions) in any step related
to the above duties, they will first be reported the primary staff member for
likely easy correction or resolution. If a pattern exists or repetitive errors are
identified through the review and verification process, the secondary reviewer
will report the issue(s) to the Department Administrator to make a
determination as to whether the primary staff member’s duties are transferred
to another staff member, or if the person is simply re-educated.
The goal will be to ensure there is an appropriate check and balance step (as
well as remediation/correction step if warranted) in place for all tasks and
documentation completion as it relates to grant-funded duties and invoicing.
Anticipated Completion Date:
We will follow this practice for any new grants accepted by the Allen County Department
of Health effective 9/17/2024.