Finding 1149405 (2024-001)

- Repeat Finding
Requirement
E
Questioned Costs
-
Year
2024
Accepted
2025-08-06
Audit: 363788
Organization: Beacon Health System, Inc. (IN)
Auditor: Rsm US LLP

AI Summary

  • Core Issue: The Corporation's eligibility screening for the WIC program relies on a paperless system, which limits the ability to verify compliance with federal eligibility requirements.
  • Impacted Requirements: The lack of retained documentation for identity, residency, and income eligibility prevents effective testing of internal controls, leading to a qualified opinion on compliance.
  • Recommended Follow-Up: No further action is needed, as management is adhering to state guidance regarding documentation retention.

Finding Text

Identification of Federal Program: Federal Agency: U.S. Department of Agriculture Food and Nutrition Service Federal Assistance Listing No.: 10.557- WIC Special Supplemental Nutrition Program for Women, Infants, and Children Pass-Through Entity: Indiana Department of Health Pass-Through Award Numbers: 3610-572900-142500 (23), 3610-572900-142500 (24) Criteria: Applicants for WIC program benefits are screened at WIC clinic sites to determine their WIC eligibility. To be certified eligible, the WIC applicant must meet the following eligibility criteria identified in 7 CFR Section 246.7(c), (d), (e): a. Categorical—Eligibility is restricted to infants and children up to age 5 and pregnant, postpartum, and breastfeeding women must: b. Identity and Residency—Except in limited circumstances, WIC applicants must be physically present for eligibility screenings and must provide proof of identity. An applicant must also meet the state agency residency requirement. Except in the case of Indian state agencies, the applicant must reside in the jurisdiction of the state. Indian state agencies may require applicants to reside within their jurisdiction. c. Income—The State agency shall establish, and provide local agencies with, income guidelines, definitions, and procedures to be used in determining an applicant’s income eligibility for the Program. d. Nutritional Risk—A competent professional authority on the staff of the local agency shall determine if a person is at nutritional risk through a medical and/or nutritional assessment. This determination may be based on referral data submitted by a competent professional authority not on the staff of the local agency. When an applicant meets all eligibility criteria, he/she is determined by WIC clinic staff to be eligible for program benefits. Certification periods are assigned to each participant based on categorical benefits. Certification periods are assigned to each participant based on categorical status for women, infants and children (7 CFR Section 246.7 (g)). Condition: The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of supporting documentation supporting the WIC applicant’s eligibility. Therefore, we were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Cause: The Corporation follows a paperless system as supported by the state of Indiana. The state does not require retention of third-party documentation supporting a WIC applicant’s eligibility determination. Effect or potential effect: Due to the online nature of the eligibility system, we were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations for federal assistance listing number 10.557. Questioned cost: none identified. Context: Federal expenditures reported in the schedule of expenditures of federal awards for assistance listing 10.557 totaled $1,844,446 for the year ended December 31, 2024. Identification as a repeat finding if applicable: Yes. Prior year finding 2022-001. Recommendation: No further follow-up is required, as management of the Corporation is following the applicable guidance.

Categories

Subrecipient Monitoring Eligibility Reporting Internal Control / Segregation of Duties

Other Findings in this Audit

Programs in Audit

ALN Program Name Expenditures
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $12.88M
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $1.84M
93.788 Opioid Str $443,071
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $156,308
93.926 Healthy Start Initiative $93,350
93.011 National Organizations for State and Local Officials $27,598