Finding 504719 (2022-002)

Federal Program Information Federal Agencies: Department of Health and Human Services Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY21; INORWB611-GY22; INORPS611-FY22; INORPS611-FY23 Awards: Assistance Listing Number 93.917 HIV Care Formula Grants (Part B) Award Periods: April 1, 2021 to March 31, 2022: April 1, 2022 to March 31, 2023; July 1, 2021 to June 30, 2022; July 1, 2022 to March 31, 2023 Description: Review and Retention of Eligibility Required Documentation Type of Finding: Material Weakness in Internal Control Over Compliance Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP “is required to collect the following documentation for client eligibility: (a) Legible documentation for proof of residency in Virginia, (b) Legible documents for proof of a medical diagnosis of a HIV disease (required only once for each client), (c) Legible documentation or proof of household income no greater than 500% of the Poverty Level Guidelines, and (d) Legible documentation for proof that the client does not have insurance (including Medicaid) or other program coverage for the services that the client is seeking from the RW Part B Program. Medicaid-enrolled clients who have access to HIV medications are not eligible for VA MAP services.” (INORWB611-GY22 – Client Eligibility Section E.1, INORPS611-FY23 Section A.1). IJP “will maintain an eligibility checklist and required eligibility documentation in one place in each client file” (INORWB611-GY22 – Client Eligibility Section E.3, INORPS611-FY23 Section A.2). Further, IJP “will verify client eligibility status prior to providing services, including HIV medication services” (INORWB611-GY22 – Client Eligibility Section E.4, INORPS611-FY23 Section A.3). IJP “will not receive reimbursement by the Department for any services provided to clients whose eligibility was not current at the time of service” (INORWB611-GY22 – Client Eligibility Section E.6, INORPS611-FY23 Section A.5). The requirements within the pass-through entity agreement with the Department are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (DHHS), U.S. Health Resources and Services Administration (HRSA). Per the National Monitoring Standards for Part B included on the official HRSA website, it is the provider/subgrantee’s responsibility to “maintain client records that contain documentation of the client’s eligibility determination, including the following: Initial Eligibility Determination and Recertification Documentation Requirements: (1) HIV diagnosis (2) Proof of residency (3) Low Income (4) Uninsured or underinsured status.” HRSA aligns with the Public Service Health Act Section 2616 – Provision of Treatment (b) (1-2) which states “to be eligible to receive assistance from a State under this section an individual shall (1) have a medical diagnosis of HIV/AIDS; and (2) be a low-income individual, as defined by the State.” Per the National Monitoring Standards for Part B included on the official HRSA website, “Income made from charges to RWHAP Part B clients or to insurance companies for services performed is considered program income.” Condition The System did not have appropriately designed internal controls in place to ensure that the documentation is obtained and reviewed to verify eligibility prior to providing services. Cause IJP has policies and procedures in place to obtain the eligibility documents from all clients and retain in their files. IJP’s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client to update the required eligibility screening and include the required documentation in the client file. Additionally, at each subsequent visit, the receptionist questions each client as to whether there have been any changes in their income or insurance status. If there are changes to the client’s eligibility status, another visit is scheduled with the eligibility worker. Management identified that these policies and procedures were not followed during the year due to lack of oversight and related under performance from various eligibility workers employed during the year.  Effect or potential effect Eligibility workers did not obtain and/or retain the required documentation related to the eligibility screening for certain clients. Services continued to be provided and related costs were reimbursed by DHHS. Based on the terms and conditions of the pass-through agreement with DHHS, the clients whose eligibility was not current at the time of service would not be considered eligible and any reimbursed cost would represent unallowable costs. Furthermore, program income represents income made from charges to RW Part B eligible clients or to insurance companies for services performed. Program income was recognized on services and charges for clients whose eligibility was not current at the time of service. For clients that received services in 2022, IJP recognized $332,344 of program income during the year. Questioned costs Indeterminable. Identification of a repeat finding This is not a repeat finding. Context During our audit, we selected a sample of 60 clients for testing and noted the following 3 exceptions: • There was no evidence of documentation obtained to prove that the client did not have insurance (including Medicaid) or other program coverage for the services provided for one client. • There was no evidence of documentation obtained to prove that the client did not have household income no greater than 500% of the Poverty Level Guidelines for one client. • The documentation for support proof that the client did not have household income no greater than 500% of the Poverty Level Guidelines was retained; however, for one client, the support indicated that they exceeded the Poverty Level Guidelines and services were provided. IJP has not completed a full review of all clients that could be impacted by the exceptions above. Further, IJP does not track reimbursed costs at the individual client level. As such, the costs associated with this finding are indeterminable. Recommendation IJP’s existing policies and procedures are in line with the requirements of the pass-through agreement with DHHS; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification including maintaining the requirement documentation for all clients. View of responsible officials Management concurs with the finding and will implement procedures to ensure that the appropriate oversight is performed with regard to eligibility.