Finding 1162410 (2024-002)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2024
Accepted
2025-11-15
Audit: 372193
Organization: Inova Health System (VA)

AI Summary

  • Core Issue: Inova Juniper Program failed to complete 24-month eligibility screenings on time, risking client eligibility for services.
  • Impacted Requirements: Compliance with federal regulations and pass-through entity agreement mandates timely documentation of residency, income, and insurance.
  • Recommended Follow-Up: Management should enhance procedures to ensure eligibility screenings are completed before the 24-month deadline, aligning dates with required documentation.

Finding Text

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP is required to “conduct and complete a full RWHAP B eligibility screening for all clients for any allowable Ryan White services prior to enrollment in the RWHAP B program and every 24-months thereafter by following the procedure from the department” (INORWB611 – Scope of Services – Section G1). The procedure from the Department of the award requires the recipient to resubmit documents for residency, household income and proof of insurance before the 24-month eligibility period ends. Condition IHS did not have appropriately designed internal controls in place to ensure that the documentation is obtained and reviewed to verify eligibility prior to the end of the 24-month period. Cause IJP has policies and procedures in place to obtain the eligibility documents from all clients and retain in their files. IJP’s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client to update the required eligibility screening and include the required documentation in the client file by the 24-month period end. Additionally, an eligibility worker is required to periodically make inquiries of the patient as to any changes of income, address, or insurance coverage. If any changes are noted, submission of proper documentation is required. If the eligibility workers do not have access to the proper reassessment requirement date, the required documentation may not be obtained by the 24 month period end. Effect or potential effect Eligibility workers did not timely obtain the required documentation related to the 24-month eligibility screening for certain clients before the required date. Based on the terms and conditions of the pass-through agreement with the Department, the clients whose eligibility was not completed by the deadline would not be considered eligible and should be discharged from the program. Questioned costs Indeterminable Costs are not tracked by client. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2023-001. Context During our audit, we selected a sample of 60 clients for testing and noted that the 24-month eligibility screening was submitted to the Department after the eligibility expiration date for 5 clients. We further evaluated the 5 clients and noted that either no services were performed prior to obtaining full eligibility screening or if services were provided, the services were fully covered by insurance. Recommendation Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility.

Corrective Action Plan

Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.

Categories

Subrecipient Monitoring Eligibility Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1162409 2024-001
    Material Weakness Repeat
  • 1162411 2024-001
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
97.036 COVID-19 - DISASTER GRANTS - PUBLIC ASSISTANCE (PRESIDENTIALLY DECLARED DISASTERS) $25.10M
12.750 UNIFORMED SERVICES UNIVERSITY MEDICAL RESEARCH PROJECTS $3.72M
93.917 HIV CARE FORMULA GRANTS $3.64M
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $3.46M
93.939 HIV PREVENTION ACTIVITIES NON-GOVERNMENTAL ORGANIZATION BASED $848,323
93.153 COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH $771,133
20.614 NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA) DISCRETIONARY SAFETY GRANTS AND COOPERATIVE AGREEMENTS $440,840
93.145 HIV-RELATED TRAINING AND TECHNICAL ASSISTANCE $256,098
93.914 HIV EMERGENCY RELIEF PROJECT GRANTS $241,844
93.399 CANCER CONTROL $239,674
93.767 CHILDREN'S HEALTH INSURANCE PROGRAM $224,095
16.753 CONGRESSIONALLY RECOMMENDED AWARDS $149,052
93.103 FOOD AND DRUG ADMINISTRATION RESEARCH $104,814
93.865 CHILD HEALTH AND HUMAN DEVELOPMENT EXTRAMURAL RESEARCH $68,472
93.397 CANCER CENTERS SUPPORT GRANTS $61,982
16.575 CRIME VICTIM ASSISTANCE $56,183
93.RD NHLBI Graft Sample and Data Collection Project $52,800
93.RD Population Health Research Support $49,458
93.RD NHLBI/Inova Pulmonary Vascular Program $47,301
93.121 ORAL DISEASES AND DISORDERS RESEARCH $31,659
93.RD Observational Prospective Study-The Diversification of the Pregnant Vaginal Microbiome $20,000
12.420 MILITARY MEDICAL RESEARCH AND DEVELOPMENT $19,150
93.837 CARDIOVASCULAR DISEASES RESEARCH $16,624
93.RD Tactile and Ultrasound Imaging Fusion for Functional Assessment of the Female Pelvic Floor $11,124
93.088 ADVANCING SYSTEM IMPROVEMENTS FOR KEY ISSUES IN WOMEN'S HEALTH $10,539
93.838 LUNG DISEASES RESEARCH $7,050
93.866 AGING RESEARCH $2,250
93.853 EXTRAMURAL RESEARCH PROGRAMS IN THE NEUROSCIENCES AND NEUROLOGICAL DISORDERS $1,594
21.027 COVID-19 - CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $1,291