Finding 12406 (2022-001)

Significant Deficiency
Requirement
A
Questioned Costs
-
Year
2022
Accepted
2023-06-20

AI Summary

  • Core Issue: There is a significant deficiency in internal controls regarding compliance, specifically related to missing eligibility screening forms for Title X clients.
  • Impacted Requirements: PPGT's procedures require that all eligibility screening forms be completed and stored for compliance, but 4 out of 25 cases were found lacking documentation.
  • Recommended Follow-Up: Train staff on the importance of maintaining proper eligibility documentation to align with PPGT’s policies.

Finding Text

Finding No. 2022-001: Allowable activities ? Significant deficiency in internal control over compliance. Criteria: PPGT?s internal control procedures over compliance specify that eligibility screening forms are completed and kept on file for all Title X clients. Condition: During allowable activities testing for Title X, 4 out of 25 client encounters tested were missing eligibility screening forms. Cause: Staff at patient care locations did not scan the forms into the program software, resulting in lack of documentation. Effect: Internal control over allowable activities was not effectively implemented to prevent noncompliance. Recommendation: Staff should be trained on the importance of maintaining eligibility documentation in accordance with PPGT?s policies. Management?s Response: See corrective action plan.

Corrective Action Plan

2022-001 Finding: Missing eligibility forms for Title X Patients Planned Parenthood of Greater Texas (PPGT) was awarded a five-year Title X grant in March 2022. At that time, it was necessary to write new policies, develop forms, trainings, and provide staff education on Title X expectations. The 2023 financial audit was the first audit of Title X since PPGT regained the program a year earlier. The audit identified gaps in understanding of front-line staff and PPGT policy. Corrective Action Plan Annual Title X training will be provided to staff Title X centers in mid-June 2023. The training will include expanded direction and provide clarity for the staff regarding the expectations around eligibility forms. In April 2023, the Sr. Grants Project Manager began performing monthly chart audits across all Title X sites to assess compliance with the 340b program. The audits review ten charts from each Title X center, chosen at random. The criteria include looking for evidence demonstrating compliance with the requirement that an eligibility Form is completed with income information and signed by the patient. Following an audit, a report is provided to the 340b committee and further corrective action will be taken as needed.

Categories

Allowable Costs / Cost Principles Eligibility Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 12407 2022-002
    Material Weakness
  • 12408 2022-001
    Significant Deficiency
  • 12409 2022-002
    Material Weakness
  • 588848 2022-001
    Significant Deficiency
  • 588849 2022-002
    Material Weakness
  • 588850 2022-001
    Significant Deficiency
  • 588851 2022-002
    Material Weakness

Programs in Audit

ALN Program Name Expenditures
93.217 Family Planning_services $432,859