Finding 1236780 (2023-015)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2023
Accepted
2026-09-25
Audit: 412274
Auditor: CBIZ CPAS PC

AI Summary

  • Core Issue: Services were charged to the Ryan White Part A program for clients who did not meet federal eligibility requirements, including lack of documentation for HIV-positive and low-income status.
  • Impacted Requirements: Federal regulations mandate proper documentation for client eligibility; failure to comply may lead to questioned costs and noncompliance.
  • Recommended Follow-Up: Implement procedures to collect and retain eligibility documentation, ensure only eligible clients are billed, and provide staff training on compliance requirements.

Finding Text

CRITERIA Federal regulations and the terms of the HIV Emergency Relief Project Grants (Ryan White Part A program) require that grantees collect and retain sufficient documentation to support the eligibility of all clients served, including proof of HIV-positive status and low-income status. Only services to eligible clients may be charged to the federal award. CONDITION AND CONTEXT During our review of client eligibility under the Ryan White Part A program, we identified instances where services were incorrectly charged to the program for clients who did not meet federal eligibility requirements. Specifically, mental health assessment services for six clients (totaling 29 services) were charged to the Ryan White Part A program, but these services were related to a different federal award. For one client reviewed in detail, the file did not contain adequate documentation of HIV-positive status, as required, nor documentation of low-income status. The lab results for 2023 noted a negative HIV test, and management’s alternative method for determining eligibility (using “undetectable” ranges from other tests) was not supported by guidance from DC Health or federal agencies. In addition, required eligibility data was not collected or retained in accordance with federal regulations. CAUSE Management relied on local reporting requirements rather than federal regulations and did not implement internal procedures to ensure that eligibility documentation was collected and retained for federal audit purposes. EFFECT OR POTENTIAL EFFECT Charging services for ineligible clients or clients without required documentation to a federal award may result in questioned costs, disallowed costs, noncompliance with federal regulations, and potential repayment of federal funds. Failure to collect and retain proper eligibility documentation undermines the integrity of UHU’s compliance with federal requirements. RECOMMENDATION We recommend that management establish and enforce procedures to ensure that eligibility documentation – including proof of HIV-positive status and low-income status – is collected and retained for all clients served under federal programs. In addition, management should ensure that only services provided to eligible clients are charged to the appropriate federal award, in accordance with federal regulations. Staff should be trained on these requirements, and regular reviews should be conducted to ensure compliance.

Corrective Action Plan

o Implement standardized intake and eligibility verification procedures. o Utilize eligibility checklists and required supporting documentation. o Verify client eligibility before services are provided or costs are charged to federal awards. o Train staff on eligibility requirements and documentation standards. o Establish supervisory review of eligibility determinations. o Conduct periodic monitoring and internal reviews to ensure continued compliance. o Address identified deficiencies timely through corrective actions and staff training.

Categories

Eligibility

Other Findings in this Audit

  • 1236723 2023-009
    Material Weakness Repeat
  • 1236724 2023-009
    Material Weakness Repeat
  • 1236725 2023-009
    Material Weakness Repeat
  • 1236726 2023-009
    Material Weakness Repeat
  • 1236727 2023-009
    Material Weakness Repeat
  • 1236728 2023-009
    Material Weakness Repeat
  • 1236729 2023-009
    Material Weakness Repeat
  • 1236730 2023-009
    Material Weakness Repeat
  • 1236731 2023-009
    Material Weakness Repeat
  • 1236732 2023-009
    Material Weakness Repeat
  • 1236733 2023-010
    Material Weakness Repeat
  • 1236734 2023-010
    Material Weakness Repeat
  • 1236735 2023-010
    Material Weakness Repeat
  • 1236736 2023-010
    Material Weakness Repeat
  • 1236737 2023-010
    Material Weakness Repeat
  • 1236738 2023-010
    Material Weakness Repeat
  • 1236739 2023-010
    Material Weakness Repeat
  • 1236740 2023-010
    Material Weakness Repeat
  • 1236741 2023-010
    Material Weakness Repeat
  • 1236742 2023-011
    Material Weakness Repeat
  • 1236743 2023-011
    Material Weakness Repeat
  • 1236744 2023-011
    Material Weakness Repeat
  • 1236745 2023-011
    Material Weakness Repeat
  • 1236746 2023-011
    Material Weakness Repeat
  • 1236747 2023-011
    Material Weakness Repeat
  • 1236748 2023-011
    Material Weakness Repeat
  • 1236749 2023-011
    Material Weakness Repeat
  • 1236750 2023-011
    Material Weakness Repeat
  • 1236751 2023-012
    Material Weakness Repeat
  • 1236752 2023-012
    Material Weakness Repeat
  • 1236753 2023-012
    Material Weakness Repeat
  • 1236754 2023-012
    Material Weakness Repeat
  • 1236755 2023-012
    Material Weakness Repeat
  • 1236756 2023-012
    Material Weakness Repeat
  • 1236757 2023-012
    Material Weakness Repeat
  • 1236758 2023-012
    Material Weakness Repeat
  • 1236759 2023-012
    Material Weakness Repeat
  • 1236760 2023-013
    Material Weakness Repeat
  • 1236761 2023-013
    Material Weakness Repeat
  • 1236762 2023-013
    Material Weakness Repeat
  • 1236763 2023-013
    Material Weakness Repeat
  • 1236764 2023-013
    Material Weakness Repeat
  • 1236765 2023-013
    Material Weakness Repeat
  • 1236766 2023-013
    Material Weakness Repeat
  • 1236767 2023-013
    Material Weakness Repeat
  • 1236768 2023-013
    Material Weakness Repeat
  • 1236769 2023-013
    Material Weakness Repeat
  • 1236770 2023-014
    Material Weakness Repeat
  • 1236771 2023-014
    Material Weakness Repeat
  • 1236772 2023-014
    Material Weakness Repeat
  • 1236773 2023-014
    Material Weakness Repeat
  • 1236774 2023-014
    Material Weakness Repeat
  • 1236775 2023-014
    Material Weakness Repeat
  • 1236776 2023-014
    Material Weakness Repeat
  • 1236777 2023-014
    Material Weakness Repeat
  • 1236778 2023-014
    Material Weakness Repeat
  • 1236779 2023-014
    Material Weakness Repeat
  • 1236781 2023-016
    Material Weakness Repeat
  • 1236782 2023-016
    Material Weakness Repeat
  • 1236783 2023-016
    Material Weakness Repeat
  • 1236784 2023-016
    Material Weakness Repeat
  • 1236785 2023-016
    Material Weakness Repeat
  • 1236786 2023-016
    Material Weakness Repeat
  • 1236787 2023-016
    Material Weakness Repeat
  • 1236788 2023-016
    Material Weakness Repeat
  • 1236789 2023-016
    Material Weakness Repeat
  • 1236790 2023-016
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.914 HIV EMERGENCY RELIEF PROJECT GRANTS $827,117
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $547,532
93.279 DRUG USE AND ADDICTION RESEARCH PROGRAMS $400,743
93.788 OPIOID STR $275,534
93.136 INJURY PREVENTION AND CONTROL RESEARCH AND STATE AND COMMUNITY BASED PROGRAMS $257,074
93.917 HIV CARE FORMULA GRANTS $58,312
93.242 MENTAL HEALTH RESEARCH GRANTS $41,967
93.855 ALLERGY AND INFECTIOUS DISEASES RESEARCH $25,429
93.940 HIV PREVENTION AND SURVEILLANCE ACTIVITIES-HEALTH DEPARTMENT BASED $4,314