Finding 1241636 (2021-009)

Finding No. 2021-009 - Special Tests and Provisions - Record of Immunization Identification of the federal program: Federal Agency: Department of Health and Human Services AL Program: 93.268 Immunization Cooperative Agreement Award Number: 5 NH23IP922587-03, 6 NH23IP922587-03, 6 NH23IP922587-02 Criteria or specific requirement (including statutory, regulatory or other citation): In accordance with 2 CFR 200.303(a), the recipient and subrecipient must establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient or subrecipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Additionally, 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: 1. CHCC did not provide all sampled Annual Site Visit Reports. 2. CHCC did not provide all sampled Patient Encounter Forms. Cause: CHCC’s current document maintenance and retention control and procedure are not designed or operating effectively. Effect or potential effect: CHCC is in noncompliance with the applicable Special Tests and Provisions - Record of Immunization. As a result, management and oversight agencies may be unable to verify that providers had properly screened for vaccine eligibility and had administered VFC vaccines only to eligible children. Questioned Costs: There are no questioned costs since the finding is non-monetary. Context: For five (or 71%) of seven providers selected for testing, CHCC did not provide the Annual Site Visit Reports with supporting medical records to verify that the required information of vaccination records was maintained by each service provider. Identification as a repeat finding, if applicable: Finding No. 2020-011. Recommendation: CHCC should improve its records management and document retention controls to ensure that documentation is available for oversight and audit purposes. Management may consider implementing centralized electronic storage and system-based retention procedures (such as the database functionality of its new financial management system). Views of Responsible Officials: CHCC 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 VFC Operations Guide, 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.