Finding 1157412 (2024-001)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2024
Accepted
2025-09-30
Audit: 369665
Auditor: Forvis Mazars

AI Summary

  • Core Issue: The Authority is not consistently entering required Medicaid ID numbers in the COMPASS system for WIC eligibility, leading to potential compliance gaps.
  • Impacted Requirements: This affects adherence to 2 CFR Part 200.303 regarding effective internal controls and documentation for Federal awards.
  • Recommended Follow-Up: Expand case reviews to include five records per staff member monthly and enhance training for staff on eligibility determinations.

Finding Text

Finding: Eligibility Federal Assistance Listing Number 10.557 WIC – Special Supplemental Nutrition Program for Women, Infants, and Children Department of Agriculture Pass-through Entity: State of Colorado Department of Public Health and Environment FAIN: 253CO701W1003 Award Date: 10/1/2024 Criteria: According to 2 CFR Part 200.303 – 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), (b) Comply with the U.S. Constitution, Federal statutes, regulations, and the terms and conditions of the Federal awards, (c) Evaluate and monitor the non-Federal entity's compliance with statutes, regulations and the terms and conditions of Federal awards. As the funds are passed through the Colorado Department of Public Health and Environment, the Authority is required to utilize the State WIC eligibility system (COMPASS). Condition: The Authority is responsible for determining client eligibility and entering data into the COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Cause: Since the Medicaid ID number is not a required field in COMPASS, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. Effect: Although the individuals were correctly determined to be eligible for the WIC program, the Authority did not enter all required information into the COMPASS system. Questioned Costs: None. Context: We tested 25 clients for the WIC program for the year ended December 31, 2024 and noted four instances in which documentation of Medicaid ID number was not included within the COMPASS system. The total clients served by the Authority during the year was 25,906. A non-statistical sampling methodology was used to select the sample. Identification as a Repeat Findings: Not applicable. Recommendation: We recommend that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. Views of Responsible Officials and Planned Corrective Actions: Agree. See separate report for planned corrective actions.

Corrective Action Plan

FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025

Categories

Matching / Level of Effort / Earmarking Subrecipient Monitoring Eligibility Reporting

Programs in Audit

ALN Program Name Expenditures
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $17.23M
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $14.08M
93.224 Covid-19 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $3.52M
93.959 Block Grants for Prevention and Treatment of Substance Abuse $2.75M
93.978 Sexually Transmitted Diseases (std) Provider Education Grants $2.41M
93.RD Usdhhs Cost Reimbursable Contracts $2.08M
93.778 Grants to States for Medicaid $1.63M
93.696 Certified Community Behavioral Health Clinic Expansion Grants $989,765
93.217 Family Planning Services $926,781
93.493 Congressional Directives $913,829
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $833,721
93.944 Human Immunodeficiency Virus (hiv)/acquired Immunodeficiency Virus Syndrome (aids) Surveillance $747,815
93.732 Mental and Behavioral Health Education and Training Grants $659,079
93.253 Poison Center Support and Enhancement Grant $657,390
93.838 Lung Diseases Research $609,444
93.268 Immunization Cooperative Agreements $563,964
93.527 Covid-19 Grants for New and Expanded Services Under the Health Center Program $509,837
97.036 Covid-19 Disaster Grants - Public Assistance (presidentially Declared Disasters) $506,972
93.788 Opioid Str $468,710
93.994 Maternal and Child Health Services Block Grant to the States $468,657
93.940 Hiv Prevention Activities Health Department Based $455,494
93.526 Grants for Capital Development in Health Centers $407,522
93.870 Maternal, Infant and Early Childhood Home Visiting Grant $405,738
93.817 Hospital Preparedness Program (hpp) Ebola Preparedness and Response Activities $365,654
93.310 Trans-Nih Research Support $321,288
93.530 Teaching Health Center Graduate Medical Education Payment $317,195
93.939 Hiv Prevention Activities Non-Governmental Organization Based $317,032
93.958 Block Grants for Community Mental Health Services $290,012
93.687 Maternal Opioid Misuse Model $268,962
93.172 Human Genome Research $268,911
93.977 Sexually Transmitted Diseases (std) Prevention and Control Grants $241,922
93.270 Viral Hepatitis Prevention and Control $239,106
93.575 Child Care and Development Block Grant $238,777
12.RD Dod Cost Reimbursable Contracts $226,921
93.304 Racial and Ethnic Approaches to Community Health $209,603
93.648 Child Welfare Research Training Or Demonstration $204,898
93.161 Health Program for Toxic Substances and Disease Registry $203,103
93.866 Aging Research $181,870
93.928 Special Projects of National Significance $178,814
93.069 Public Health Emergency Preparedness $170,743
16.753 Congressionally Recommended Awards $170,000
93.268 Covid-19 Immunization Cooperative Agreements $166,455
17.258 Wioa Adult Program $145,067
93.825 National Ebola Training and Education Center (netec) $141,983
93.350 National Center for Advancing Translational Sciences $124,623
16.582 Crime Victim Assistance/discretionary Grants $121,540
93.161 Covid-19 Health Program for Toxic Substances and Disease Registry $120,062
93.116 Project Grants and Cooperative Agreements for Tuberculosis Control Programs $112,940
93.233 National Center on Sleep Disorders Research $111,165
16.575 Crime Victim Assistance $104,270
93.840 Covid-19 Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders $86,089
93.967 Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health $75,939
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $72,614
93.884 Primary Care Training and Enhancement $66,260
93.242 Mental Health Research Grants $57,740
21.027 Covid-19 Coronavirus State and Local Fiscal Recovery Funds $56,537
93.889 National Bioterrorism Hospital Preparedness Program $51,816
93.317 Emerging Infections Programs $50,470
93.307 Covid-19 Minority Health and Health Disparities Research $46,981
16.590 Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program $45,708
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $45,155
93.173 Research Related to Deafness and Communication Disorders $41,854
12.420 Military Medical Research and Development $35,589
93.859 Biomedical Research and Research Training $29,037
93.279 Drug Use and Addiction Research Programs $28,959
93.847 Covid-19 Diabetes, Digestive, and Kidney Diseases Extramural Research $27,301
93.191 Graduate Psychology Education $26,824
93.516 Public Health Training Centers Program $22,291
93.297 Teenage Pregnancy Prevention Program $20,438
93.755 Surveillance for Diseases Among Immigrants and Refugees Financed in Part by Prevention and Public Health Funds (pphf) $20,186
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $19,375
47.083 Integrative Activities $17,973
93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance $16,611
93.226 Research on Healthcare Costs, Quality and Outcomes $16,067
93.527 Grants for New and Expanded Services Under the Health Center Program $15,712
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $13,976
93.600 Head Start $13,519
93.865 Child Health and Human Development Extramural Research $12,793
93.834 Capacity Building Assistance (cba) for High-Impact Hiv Prevention $12,485
93.604 Assistance for Torture Victims $12,186
93.855 Allergy and Infectious Diseases Research $10,784
93.310 Covid-19 Trans-Nih Research Support $9,908
93.436 Well-Integrated Screening and Evaluation for Women Across the Nation (wisewoman) $9,803
93.837 Cardiovascular Diseases Research $6,560
93.399 Cancer Control $6,187
93.945 Assistance Programs for Chronic Disease Prevention and Control $5,311
93.323 Covid-19 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $4,053
93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund $3,969
93.556 Marylee Allen Promoting Safe and Stable Families Program $3,788
93.110 Maternal and Child Health Federal Consolidated Programs $3,446
93.393 Cancer Cause and Prevention Research $2,614
93.136 Injury Prevention and Control Research and State and Community Based Programs $1,071
93.991 Preventive Health and Health Services Block Grant $782
93.575 Covid-19 Child Care and Development Block Grant $756
93.117 Preventive Medicine Residency $73
93.917 Hiv Care Formula Grants $-2
93.361 Nursing Research $-55
93.391 Covid-19 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $-546
93.435 The Innovative Cardiovascular Health Program $-903
93.989 International Research and Research Training $-982
93.879 Medical Library Assistance $-1,004
93.840 Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders $-2,057
93.135 Centers for Research and Demonstration for Health Promotion and Disease Prevention $-2,134
93.914 Hiv Emergency Relief Project Grants $-2,639
93.800 Organized Approaches to Increase Colorectal Cancer Screening $-3,255
21.019 Covid-19 Coronavirus Relief Fund $-21,193
93.395 Cancer Treatment Research $-56,236
93.978 Covid-19 Sexually Transmitted Diseases (std) Provider Education Grants $-119,300