FAC Explorer

Finding 1179807 (2020-011)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2020
Accepted
2026-03-16
Audit: 392188
Organization: Commonwealth Healthcare Corporation (MP)
Auditor: ERNST & YOUNG (CNMI) INC

AI Summary

  • Core Issue: CHCC failed to provide Site Visit Reports for 83% of selected providers, indicating a lack of compliance with VFC program requirements.
  • Impacted Requirements: The absence of documentation violates the VFC Policies and Procedures, specifically the need for annual evaluations of vaccination records.
  • Recommended Follow-Up: CHCC should enhance record-keeping practices, including digitizing documents, to ensure better management transitions and compliance with VFC standards.

Finding Text

Federal Agency: Department of Health and Human Services CFDA Program: 93.268 Immunization Cooperative Agreement Award Number: 1NH23IP922587-01-00, 6NH23IP922587-01-01, 6NH23IP922587-01-02, 5NH23IP922587-02-00, 6 NH23IP922587-02-01 and 6NH23IP000736 Area: Special Tests and Provision – Record of Immunization Questioned Costs: $ -0- Criteria: In accordance with the Vaccine for Children Program (VFC) Policies and Procedures at the State/Local Immunization Program section 4.1, visits must be conducted on an annual or as per need basis which evaluates the program’s adherence to VFC program requirements including sampling patient records to verify eligibility screening and the administration of VFC vaccine only to eligible children. Condition For five (or 83%) of six providers selected for testing, CHCC was unable to provide the Site Visit Reports to verify that the required information of vaccination records was maintained by each service provider. Cause: CHCC was unable to provide the supporting documents as it was lost during the transition to the new management and their current control and procedures are not suitably designed to properly maintain and retain all the documents. Effect: The CHCC is in noncompliance with the applicable Special Tests and Provisions – Record of Immunization. Recommendation: CHCC should improve their record-keeping policies and controls, such as duplication of documents into a soft copy, to ensure that a seamless transition is achieved whenever changes to management take into effect. Views of Responsible Officials: CHCC partially concurs with the finding. Since 2020, the CHCC has conducted the following steps to ensure that annual site visits for VFC providers are completed and documented appropriately to evaluate adherence to the VFC program requirements: - Worked with CDC Subject Matter Experts to ensure that data systems for site visit findings/reporting were accessible to the VFC Coordinator. Training on the system was also provided to the VFC Coordinator. This system is cloud based and accessible to anyone provided access. Therefore, should staff turnover occur, access to prior reports and the system for submitting new site visit reports will continue to be accessible to the organization and to team members who will take on the responsibility. - Ensure that Position Descriptions for the VFC Coordinator clearly specify responsibilities for implementing the VFC Program in accordance with the Immunization Program Operating Manual (IPOM), which outlines the requirements for annual provider compliance site visits, including the sampling of patient records to verify eligibility screening and administration of VFC vaccine only to eligible children. - Provided training/refresher to the staff member assigned/responsible (VFC Coordinator) for conducting site visits - Timeliness and completeness of site visit entries have been incorporated as part of the program’s activity workplan.

Corrective Action Plan

Finding No.: 2020-011 CFDA Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision – Record of Immunization Questioned Costs: $-0- Contact Person(s): Program Manager, Director of Public Health Services Corrective Action Plan: CHCC partially concurs with the finding. Since 2020, the CHCC has conducted the following steps to ensure that annual site visits for VFC providers are completed and documented appropriately to evaluate adherence to the VFC program requirements: - Worked with CDC Subject Matter Experts to ensure that data systems for site visit findings/reporting were accessible to the VFC Coordinator. Training on the system was also provided to the VFC Coordinator. This system is cloud based and accessible to anyone provided access. Therefore, should staff turnover occur, access to prior reports and the system for submitting new site visit reports will continue to be accessible to the organization and to team members who will take on the responsibility Corrective Action Plan, continued: - Ensure that Position Descriptions for the VFC Coordinator clearly specify responsibilities for implementing the VFC Program in accordance with the Immunization Program Operating Manual (IPOM), which outlines the requirements for annual provider compliance site visits, including the sampling of patient records to verify eligibility screening and administration of VFC vaccine only to eligible children. - Provided training/refresher to the staff member assigned/responsible (VFC Coordinator) for conducting site visits - Timeliness and completeness of site visit entries have been incorporated as part of the program’s activity workplan. It’s also important to note that during this time, the Immunization Program was responding to the National Health Emergency with the COVID-19 pandemic. Proposed Completion Date: On-going

Categories

Special Tests & Provisions Eligibility Reporting

Other Findings in this Audit

  • 1179797 2020-004
    Material Weakness Repeat
  • 1179798 2020-005
    Material Weakness Repeat
  • 1179799 2020-006
    Material Weakness Repeat
  • 1179800 2020-004
    Material Weakness Repeat
  • 1179801 2020-005
    Material Weakness Repeat
  • 1179802 2020-006
    Material Weakness Repeat
  • 1179803 2020-007
    Material Weakness Repeat
  • 1179804 2020-008
    Material Weakness Repeat
  • 1179805 2020-009
    Material Weakness Repeat
  • 1179806 2020-010
    Material Weakness Repeat
  • 1179808 2020-012
    Material Weakness Repeat
  • 1179809 2020-013
    Material Weakness Repeat
  • 1179810 2020-014
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $3.54M
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $2.73M
15.875 ECONOMIC, SOCIAL, AND POLITICAL DEVELOPMENT OF THE TERRITORIES $1.28M
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $1.09M
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $867,903
93.323 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $830,826
93.982 MENTAL HEALTH DISASTER ASSISTANCE AND EMERGENCY MENTAL HEALTH $616,525
93.136 INJURY PREVENTION AND CONTROL RESEARCH AND STATE AND COMMUNITY BASED PROGRAMS $575,366
93.104 COMPREHENSIVE COMMUNITY MENTAL HEALTH SERVICES FOR CHILDREN WITH SERIOUS EMOTIONAL DISTURBANCES (SED) $527,553
93.354 PUBLIC HEALTH EMERGENCY RESPONSE: COOPERATIVE AGREEMENT FOR EMERGENCY RESPONSE: PUBLIC HEALTH CRISIS RESPONSE $523,298
93.116 PROJECT GRANTS AND COOPERATIVE AGREEMENTS FOR TUBERCULOSIS CONTROL PROGRAMS $511,398
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $440,199
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $406,798
93.236 GRANTS TO STATES TO SUPPORT ORAL HEALTH WORKFORCE ACTIVITIES $394,060
93.069 PUBLIC HEALTH EMERGENCY PREPAREDNESS $386,129
97.088 DISASTER ASSISTANCE PROJECTS $383,157
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $311,866
93.217 FAMILY PLANNING SERVICES $307,887
93.788 OPIOID STR $285,432
93.889 NATIONAL BIOTERRORISM HOSPITAL PREPAREDNESS PROGRAM $224,726
93.377 PREVENTION AND CONTROL OF CHRONIC DISEASE AND ASSOCIATED RISK FACTORS IN THE U.S. AFFILIATED PACIFIC ISLANDS, U.S. VIRGIN ISLANDS, AND P. R. $162,175
93.958 BLOCK GRANTS FOR COMMUNITY MENTAL HEALTH SERVICES $131,753
93.251 EARLY HEARING DETECTION AND INTERVENTION $131,198
93.165 GRANTS TO STATES FOR LOAN REPAYMENT $125,000
93.504 FAMILY TO FAMILY HEALTH INFORMATION CENTERS $81,866
93.917 HIV CARE FORMULA GRANTS $56,747
93.110 MATERNAL AND CHILD HEALTH FEDERAL CONSOLIDATED PROGRAMS $54,367
93.150 PROJECTS FOR ASSISTANCE IN TRANSITION FROM HOMELESSNESS (PATH) $48,878
93.991 PREVENTIVE HEALTH AND HEALTH SERVICES BLOCK GRANT $44,182
93.644 ADULT MEDICAID QUALITY: IMPROVING MATERNAL AND INFANT HEALTH OUTCOMES IN MEDICAID AND CHIP $33,438
93.314 EARLY HEARING DETECTION AND INTERVENTION INFORMATION SYSTEM (EHDI-IS) SURVEILLANCE PROGRAM $21,160
93.103 FOOD AND DRUG ADMINISTRATION RESEARCH $20,000
93.665 EMERGENCY GRANTS TO ADDRESS MENTAL AND SUBSTANCE USE DISORDERS DURING COVID-19 $9,691
16.575 CRIME VICTIM ASSISTANCE $5,730
93.817 HOSPITAL PREPAREDNESS PROGRAM (HPP) EBOLA PREPAREDNESS AND RESPONSE ACTIVITIES $3,573