Finding 1205370 (2025-101)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2025
Accepted
2026-03-31
Audit: 397064
Organization: Cochise County (AZ)

AI Summary

  • Core Issue: The County failed to require program participants to complete and sign a rights and obligations form, increasing the risk of ineligible individuals receiving benefits.
  • Impacted Requirements: This oversight violates federal regulations and State policies regarding eligibility certification and proper separation of duties among staff.
  • Recommended Follow-Up: Ensure compliance by mandating the signing of rights and obligations forms and providing necessary training to staff on eligibility certification processes.

Finding Text

The County did not perform eligibility certification requirements, resulting in an increased risk of program participants receiving benefits they are not eligible to receive Assistance Listings number(s) and name(s): 10.557 WIC Special Supplemental Nutrition Program for Women, Infants, and Children Award number(s) and year(s): CTR067930 October 1, 2023 through September 30, 2028 Federal agency: U.S. Department of Agriculture Pass-through grantor(s): Arizona Department of Health Services Compliance requirement(s): Eligibility Questioned costs: Unknown Condition Contrary to federal regulations and State policies, the County’s Health and Social Services Department (Department) issued program benefits without requiring each program participant to complete and sign a rights and obligations form during the eligibility certification process agreeing to provide current and truthful information, abide by program rules, and not share WIC benefits cards or other benefits. Specifically, for 17 of 60 participants tested, the Department did not require the participants to complete and sign a rights and obligations form for 9 participants’ initial certifications and 8 participants’ recertification for ongoing benefits. In addition, for 5 of 60 participants tested, the Department did not properly separate duties and allowed the same employee to determine eligibility and issue benefits to participants. Further, we found that 2 of 13 WIC employees responsible for determining a participant’s eligibility did not complete mandatory annual training. Effect The Department’s not requiring program participants to acknowledge their rights and obligations increases the risk of participants providing inaccurate information required for eligibility determinations, such as erroneous residency and income data that could allow program participants to receive benefits they are not eligible to receive. Further, there is an increased risk of misuse of program benefits received as the participants may not be aware of the program’s rules and could allow others to use their WIC benefits cards or inappropriately sell, trade, or give away benefits received, such as food, formula, or breast pumps. Finally, the Department’s not properly separating duties or providing mandatory annual training increases the risk of fraud and awarding benefits to ineligible participants. Cause Department management reported that there was misdirection by the previous WIC director who communicated to staff that only the participation consent form, not the rights and obligations form, was required to be signed. In addition, Department management reported that for part of the fiscal year when 2 employees were updating a participant’s information at the same time, the employees did not properly save who completed a participant’s eligibility determination and who approved it in the State’s eligibility system. Further, the Department did not perform periodic monitoring to ensure (1) Department clinic site staff required participants to sign the rights and obligations form prior to issuing benefits and that the forms were maintained in the State’s eligibility system, (2) separation of duties was properly documented in the State’s eligibility system, or (3) WIC employees responsible for determining a participant’s eligibility completed mandatory annual training. Criteria Federal regulation and State policies require participants to sign a rights and obligations statement as part of the eligibility-certification process (7 CFR §246.7[i][10]). Specifically, State eligibility-certification policies require the Department’s staff who are responsible for the eligibility-certification process to inform participants of their rights and obligations prior to issuing benefits during the participant’s initial certification and recertifications for ongoing benefits. Also, the participants must complete and sign the form acknowledging their rights and obligations, including: Providing the most current and truthful information that WIC staff may verify. Following the WIC program’s rules to avoid being prosecuted, disqualified, and/or asked to repay the program. Allowing only the approved authorized recipient or proxy to use the WIC benefits card and reporting lost or stolen WIC benefits cards. Being honest and not selling, trading, or giving away WIC benefits cards, food, formula, or breast pumps, and acknowledging that doing so will disqualify the recipient from benefits. In addition, policies and procedures over WIC certifications completed at a local agency should prohibit 1 employee from determining eligibility for all certification criteria and issuing benefits to participants or provide effective alternative policies and procedures when separation of duties is not possible (7 CFR §246.4[a][27][iii]). Further, State pass-through entity grant award requires the Department to provide training to all WIC employees responsible for determining a participant’s eligibility. Finally, federal guidelines require establishing and maintaining effective internal control over federal awards that provides reasonable assurance that federal programs are being managed in compliance with all applicable laws, regulations, and award terms (2 CFR §200.303). Recommendations to the Department Follow the State’s eligibility certification policies that require program participants to complete and sign a rights and obligations form prior to the Department issuing benefits during initial certifications and recertifications for ongoing benefits. Train Department staff, who are responsible for the eligibility certification process, as required by the State pass-through, regarding the following requirements: Participants must be informed of their rights and obligations prior to issuing benefits during the participant’s initial certification and recertifications for ongoing benefits. Participants must sign the rights and obligations form during the eligibility certification process agreeing to provide current and truthful information, abide by program rules, and not share WIC benefits cards or other benefits. Department staff must maintain the forms in its eligibility system. Separate job responsibilities in policies and procedures to prohibit 1 employee from determining eligibility for all certification criteria and issuing benefits to participants or provide effective alternative policies and procedures when separation of duties is not possible. Perform periodic monitoring at its clinic sites to ensure: Department clinic site staff require participants to sign the rights and obligations form prior to issuing benefits and that the forms are maintained in the State’s eligibility system. Separation of duties is properly documented in the State’s eligibility system. WIC employees responsible for determining a participant’s eligibility complete mandatory training. This finding is similar to prior-year finding 2024-101 and was initially reported in fiscal year 2024. Views of responsible officials County management concurs with this finding. The County’s corrective action plan at the end of this report includes the views and planned corrective action of its responsible officials regarding these recommendations. We are not required to audit and have not audited these responses and planned corrective actions and therefore provide no assurances as to their accuracy.

Corrective Action Plan

Cochise County Corrective Action Plan Year ended June 30, 2025 2025-101 Assistance Listings number and name: 10.557 WIC Special Supplemental Nutrition Program for Women, Infants, and Children Award number and years: CTR067930, October 1, 2023 through September 30, 2028 Federal agency: U.S. Department of Agriculture Pass-through grantor: Arizona Department of Health Services Compliance requirement: Eligibility Questioned costs: Unknown The County did not perform eligibility certification requirements, resulting in an increased risk of program participants receiving benefits they are not eligible to receive Contact: Barbara Lang Completion date: March 2026 Corrective Action: Cochise County WIC leadership and staff are committed to full adherence with WIC policy and will continue to implement training, monitoring, and communication to ensure compliance with federal and state regulation. This audit timeframe produced findings primarily related to issues that have already been corrected through the departure of staff that contributed to the findings (to include the previous Directors), hiring of new staff with a more thorough and comprehensive training plan implemented, and staff effort to retroactively collect all required signatures at subsequent appointments to ensure all WIC clients have current signatures and understanding of Rights & Obligations and Consents for their certification period. We recognize that these new processes were not put into plan until June 2025, due to the timing of the previous audit, and therefore did not reflect on the July 1, 2024 – June 30, 2025 audit period. In addition to the above resolved issues, a new WIC director was hired in September 2025 and new policies and procedures were immediately developed and put into place. These new policies and procedures that serve as our already implemented corrective action plan are as follows: Staff Training a. All staff are required to complete the full ADHS WIC-sponsored live cohort training courses upon hire, and every 3 years of their employment to ensure competencies are maintained over time. b. All staff complete their annual Civil Rights, Conflict of Interest, and Confidentiality upon hire and annually. Last annual training was completed Fall 2025. c. A staff dedicated as Training Coordinator monitors training logs and ensure all training requirements are met, with additional oversight by the WIC Director and the ADHS WIC State office. d. In-person staff meetings are held monthly, with a significant portion of time dedicated to staff training on programmatic expectations to ensure all staff obtain the same information so that tasks are carried out in a standardized method. e. Weekly team huddles to review any timely findings or discuss issues as a group. f. Weekly 1:1’s with each staff to discuss areas where the employee may need additional training or to discuss any deficiencies the WIC manager has noticed, (i.e. note-taking/documentation, single income verifications, chart review findings, etc.). Separation of Duties g. Cert List for Audits report run every 2 weeks for each clinic/staff person to review adherence to Separation of Duties. i. Follow up with certain percentage of clients per policy to assess how the certification went and verify client information. ii. Follow up with staff if any issues are identified. h. Staff have been training on during staff meetings in July 2025, August 2025, October 2025, and during new employee training on how to properly use the HANDS system to ensure the system accurately records who completed the 2nd income verification. i. Revision of Separation of Duties policy and implementation of new “protected time” procedure to ensure there is a staff person available at almost all times of day to complete the 2nd IV. *Since approval of this policy the ADHS WIC state office on 1/5/2026 and implementation of this policy/procedure, the Cert List for Audit report of single-income verifications has decreased substantially (from 60 in 2 weeks, to 5), all with documented reasons why 2nd IV was unable to be obtained during certification appointment and notes verifying 2nd IV was completed on another date. Rights and Obligations and Consent Forms a. All staff received a refresher training on 8/26/25, will be retrained annually, and are regularly reminded to obtain both required signatures at certification b. If staff are unable to obtain digital signatures due to tech issues, they are required to obtain e-document signatures via the clients email, or written signatures the staff then scans into the client file c. Chart reviews and staff observations are completed on a monthly-bimonthly basis to ensure ongoing staff compliance with policy and procedure

Categories

Subrecipient Monitoring Eligibility Procurement, Suspension & Debarment Reporting

Programs in Audit

ALN Program Name Expenditures
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $1.25M
21.032 LOCAL ASSISTANCE AND TRIBAL CONSISTENCY FUND $749,035
16.710 PUBLIC SAFETY PARTNERSHIP AND COMMUNITY POLICING GRANTS $682,356
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $648,381
20.106 AIRPORT IMPROVEMENT PROGRAM, INFRASTRUCTURE INVESTMENT AND JOBS ACT PROGRAMS, AND COVID-19 AIRPORTS PROGRAMS $417,452
97.067 HOMELAND SECURITY GRANT PROGRAM $413,480
14.228 COMMUNITY DEVELOPMENT BLOCK GRANTS/STATE'S PROGRAM AND NON-ENTITLEMENT GRANTS IN HAWAII $343,615
66.818 BROWNFIELDS MULTIPURPOSE, ASSESSMENT, REVOLVING LOAN FUND, AND CLEANUP COOPERATIVE AGREEMENTS $327,361
14.241 HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS $252,184
16.609 PROJECT SAFE NEIGHBORHOODS $242,459
14.871 SECTION 8 HOUSING CHOICE VOUCHERS $235,708
95.001 HIGH INTENSITY DRUG TRAFFICKING AREAS PROGRAM $224,957
93.069 PUBLIC HEALTH EMERGENCY PREPAREDNESS $213,539
93.788 OPIOID STR $208,982
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $203,963
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $174,909
20.205 HIGHWAY PLANNING AND CONSTRUCTION $164,839
97.042 EMERGENCY MANAGEMENT PERFORMANCE GRANTS $136,716
97.047 BRIC: BUILDING RESILIENT INFRASTRUCTURE AND COMMUNITIES $118,097
16.738 EDWARD BYRNE MEMORIAL JUSTICE ASSISTANCE GRANT PROGRAM $104,044
10.665 SCHOOLS AND ROADS - GRANTS TO STATES $103,252
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $93,341
14.896 FAMILY SELF-SUFFICIENCY PROGRAM $91,006
16.575 CRIME VICTIM ASSISTANCE $85,357
84.425 EDUCATION STABILIZATION FUND $81,270
93.136 INJURY PREVENTION AND CONTROL RESEARCH AND STATE AND COMMUNITY BASED PROGRAMS $73,646
84.027 SPECIAL EDUCATION GRANTS TO STATES $56,148
93.991 PREVENTIVE HEALTH AND HEALTH SERVICES BLOCK GRANT $51,344
93.977 SEXUALLY TRANSMITTED DISEASES (STD) PREVENTION AND CONTROL GRANTS $29,204
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $27,051
93.354 PUBLIC HEALTH EMERGENCY RESPONSE: COOPERATIVE AGREEMENT FOR EMERGENCY RESPONSE: PUBLIC HEALTH CRISIS RESPONSE $24,594
93.597 GRANTS TO STATES FOR ACCESS AND VISITATION PROGRAMS $18,764
20.600 STATE AND COMMUNITY HIGHWAY SAFETY $16,531
16.839 STOP SCHOOL VIOLENCE $11,581
10.U01 NATIONAL FOREST SYSTEM - LAW ENFORCEMENT $10,576
20.616 NATIONAL PRIORITY SAFETY PROGRAMS $10,398
93.658 FOSTER CARE TITLE IV-E $8,329
93.563 CHILD SUPPORT SERVICES $6,881
84.184 SCHOOL SAFELY NATIONAL ACTIVITIES $4,340
93.103 FOOD AND DRUG ADMINISTRATION RESEARCH $3,616