Finding 411137 (2022-001)

Significant Deficiency
Requirement
AB
Questioned Costs
-
Year
2022
Accepted
2023-01-10
Audit: 312028
Organization: The Haven (AZ)

AI Summary

  • Core Issue: The Organization lacks sufficient controls over user access to electronic health records for SABG-funded services.
  • Impacted Requirements: Compliance with U.S. Department of Health and Human Services standards for allowable costs and activities.
  • Recommended Follow-Up: Implement procedures to document and review user access to electronic health records effectively.

Finding Text

Finding Number 2022-001 Internal Controls over Activities Allowed or Unallowed and Allowable Costs/Cost Principles, Substance Abuse Prevention and Treatment Block Grant (SABG), ALN 93.959, October 1, 2021 through September 30, 2022 (Significant Deficiency).Statement of Condition:The Organization does not have adequate controls over user access to its electronic health records used for services funded by SABG.Questioned Costs:None.Criteria:The Organization must comply with activities allowed or unallowed and allowable costs/cost principles standards as set by the U.S. Department of Health and Human Services.Cause:The Organization did not adequately set controls over user access to its electronic health records.Effect:With the absence of adequate controls, the Organization could bill for services not allowed by the grant.Recommendation:We recommend the Organization make the necessary changes to ensure user access to its electronic health record is adequately documented and reviewed.Management Response:Management agrees with the finding. Procedures are being implemented to ensure a level of review over changes to the Organization?s electronic health records.

Corrective Action Plan

2022-001 Excessive number of Super Users in KIPU medical record system and Alli Lippard's (Billing Manager) practice of changing billing codes without supervision.The Haven reduced the number of Super Users to three Suzi Armenta (IT Manager), Kristin Lindberg (Quality Director), and Allie Lippard on November 18, 2022.Allie Lippard sends a spreadsheet to Cynthia Duncan (Finance Director), Ryan Olson (Acting Clinical Director), and Jody Little (Outpatient Program Manager) documenting code changes required and the reason for the change. Cynthia Duncan will affirm the changes in an email response.When the charges are transferred to the Billing system Allie Lippard will run a report showing the charges in the Billing system and Cynthia Duncan will affirm via email that the charges match the modified data set. This process will be complete December 19th, 2022.

Categories

Allowable Costs / Cost Principles Significant Deficiency

Other Findings in this Audit

  • 411138 2022-001
    Significant Deficiency
  • 411139 2022-002
    Significant Deficiency
  • 411140 2022-002
    Significant Deficiency
  • 987579 2022-001
    Significant Deficiency
  • 987580 2022-001
    Significant Deficiency
  • 987581 2022-002
    Significant Deficiency
  • 987582 2022-002
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.959 Block Grants for Prevention and Treatment of Substance Abuse $272,658
93.498 Provider Relief Fund $84,925
97.114 Emergency Food and Shelter National Board Program (arra) $11,250