Finding 571267 (2023-004)

Significant Deficiency
Requirement
E
Questioned Costs
-
Year
2023
Accepted
2025-07-14

AI Summary

  • Core Issue: Intake forms for AAA services lack required case worker signatures, indicating incomplete eligibility reviews.
  • Impacted Requirements: Compliance with the Older Americans Act mandates that both client and case worker signatures are necessary for proper eligibility documentation.
  • Recommended Follow-Up: Strengthen controls by enforcing signature policies, adding a secondary review process, and training staff on documentation standards.

Finding Text

Federal Program: Area Agency on Aging (AAA) – Various ALNs under the Older Americans Act (e.g., 93.044, 93.045, 93.052) Compliance Requirement: Eligibility and Documentation Requirements Type of Finding: Internal Control Deficiency Condition: During our review of client intake documentation for services provided under the AAA programs, we identified multiple instances in which intake forms were not signed by the assigned case worker. While client demographic information and signatures were present, the absence of case worker signatures indicates that formal review and approval of client eligibility and service initiation was incomplete in accordance with established procedures. Criteria: Per Older Americans Act program guidance, eligibility determinations and service documentation must be reviewed and authorized by qualified staff. Standard internal control practices further require that intake forms be signed and dated by both the client and the case worker to provide audit evidence of eligibility assessment and case manager oversight. The case worker’s signature serves as confirmation that intake information was reviewed for accuracy, eligibility criteria were met, and services were appropriately initiated. Cause: The condition appears to result from inconsistent application of intake protocols and a lack of secondary review to ensure completion of required documentation fields, including the case worker’s signature. Effect: Incomplete intake documentation compromises the integrity of the client eligibility process and increases the risk of noncompliance with federal program standards. It may also impair the agency’s ability to demonstrate proper eligibility determination and oversight in the event of federal or state monitoring. Recommendation: We recommend that STDC strengthen controls over the intake and eligibility documentation process by: • Reinforcing existing policies that require case worker signatures on all intake forms; • Implementing a secondary review or quality assurance step prior to initiating services to verify that all required documentation, including signatures, is present; • Providing targeted training to intake and case management staff on documentation standards and accountability requirements under Older Americans Act programs. Questioned Costs: None

Corrective Action Plan

STDC concurs with the finding regarding incomplete intake documentation due to the absence of case worker signatures on multiple client intake forms under the Area Agency on Aging (AAA) programs. While client eligibility and demographic information were present, the lack of formal sign-off by the assigned case worker represents a lapse in documentation compliance and internal control. STDC management acknowledges the importance of complete and accurate documentation to uphold program integrity and compliance with the Older Americans Act. We are fully committed to strengthening internal controls, reinforcing training, and implementing procedural safeguards to ensure that all eligibility determinations and service authorizations are properly reviewed and documented. To address this, STDC will reinforce existing policies requiring case worker authorization of client intakes, implement a formal quality assurance checkpoint before service initiation, and provide refresher training to all intake and case management staff. These steps will ensure compliance with documentation standards required under the Older Americans Act and STDC’s own internal procedures. Corrective Action Plan Finding Number: 2023-04 Planned Completion Date: July 31, 2025 Responsible Official: Aging and Disability Services Director Corrective Actions: 1. Reinforce Policy Compliance through Staff Training The Aging and Disability Services Director will conduct mandatory refresher training for all intake and case management staff. The training will emphasize the importance of complete documentation, specifically the requirement to sign and date all applicable forms, including: o Intake Forms 2270 and 2276 o Rights and Responsibilities Form 2275 o Client Information Release Form 2277 o Care Plan o Caregiver Assessment o Consumer Needs Evaluation (CNE) o Evaluation of the Home (Housing Assessment) Staff training shall be verified for completion using: training attendance logs, training agenda, and post-training quiz results. 2. Implement a Secondary Review Process (Quality Assurance Checkpoint) The Aging and Disability Services Director will establish a secondary quality assurance review by the Contract Manager or other designated staff prior to initiating services. The reviewer will confirm that all required forms are fully completed and include both client and case worker signatures. 3. Update Intake Documentation Checklist and Procedures-Attached The Aging and Disability Services Director will revise the internal Required Documentation Checklist to include a checkbox for verifying the presence of AAA staff signatures and dates on all applicable forms. The updated checklist will be implemented in all new client intake files. CASE FILE CHECKLIST 1. Referral and Screening The referral and screening process begins with the Information, Referral, and Assistance (I&R/A) staff, who receive the client’s initial inquiry or service request. Once initial details are collected, the referral is assigned to a designated AAA case manager for follow-up. Screening The case manager reviews the client’s records to verify information gathered during the referral. This step helps determine eligibility (typically for individuals aged 60 and over) and whether the client qualifies for AAA services or should be referred externally. The screening must include: o Medical history o Employment background o Home environment o Self-care ability o Socioeconomic and financial status o Services received in the past o General demographics and needs o Past and current health conditions o Physical, emotional, and cognitive functioning o Living arrangements and home safety o Health insurance coverage and benefits Referral and screening documentation must be included in the client’s file to support coordination, follow-up, and accountability. 2. Intake – Form 2270 (Applicable to Caregiver Support Coordination) This form is required and must be completed by AAA staff or the case manager to collect demographic information necessary to determine eligibility. The form must include: o Initial Intake Completion – Form 2270 o Client Rights and Responsibilities (read and checked off as explained) o Part I – Recipient Identification o Part II – Services Requested o Part III – Emergency Contact Information o Part IV – Relationship to Care Recipient o Part V – Care Recipient Identification AAA staff signature and date 3. Intake – Form 2276 (Applicable to Care Coordination Support) This form is required and must be completed by AAA staff or the case manager to collect demographic information necessary to determine eligibility. The form must include: o Initial Intake Completion – Form 2276 o Client Rights and Responsibilities (read and checked off as explained) o Part I – Recipient Identification o Part II – Services Requested o Part III – Emergency Contact Information o Part IV – If referred, enter referred by; if not, leave blank o AAA staff signature and date Forms must be fully and accurately completed and include the printed name or signature of the AAA staff completing the intake, along with the date. 4. Client Rights and Responsibilities – Form 2275 This form is provided and explained to the client. A copy must be given to the client. The form must include: o Explanation of client rights and responsibilities o Client signature and date Must be signed and dated by the participant/client. 5. Client Information Release – Form 2277 This form serves as authorization to release client information to support assessment, service arrangement, and coordination of care. The form must include: o Individual’s name and WellSky ID o Completion of Parts A, B, and C o Client signature and date in Part C A copy must be provided to the client. 6. Care Plan (15–25 minutes – form attached) The care plan is developed collaboratively with the client and/or caregiver and is based on preferences, identified needs, and available resources. It outlines specific services to be provided and desired outcomes. The Care Plan Form must include: o Complete client information o Type of service (e.g., Respite, Homemaker, Personal Assistance, or other services such as Residential Repair, Health Maintenance, or ERS) o Number of units or hours per day/week (if applicable) o Duration of services o Objectives and care-related goals o Self-care resources o Desired results and measurable outcomes The form must be signed and dated by the client and/or caregiver and AAA staff/Care Coordinator. 7. Caregiver Assessment – AIAAA CAQ E 3.0 (15–25 minutes – form attached) Only applicable for Caregiver Support Coordination case files. This assessment identifies caregiver needs, strengths, limitations, and stressors to support effective care planning. The form must include: o Complete caregiver information o Caregiver needs and profile o Skills and training assessment o Caregiver stress interview o Priority status o Optional targeting categories o Additional notes, if applicable Must include the printed name or signature of the AAA staff completing the assessment and the date of completion. 7. Consumer Needs Evaluation (CNE) (form attached) The CNE documents the client’s impairment level and helps determine eligibility for services. The evaluation must include: o Completion of Parts I–V o Classification of impairment level (low, moderate, or high), based on functional needs o Consideration of mobility, self-care, cognitive ability, and support systems The form must be signed and dated by the AAA staff member completing the evaluation. 8. Comprehensive Assessment & Statement of Need (form attached) This assessment provides a holistic view of the client’s condition and support needs. The form must include: o Complete client information o Documentation of physical, mental, and medical conditions o Identification of mobility limitations o Functional/physical status – check all that apply o List of current services or treatments being received o Family caregiver support o Medication listing, if applicable AAA staff must complete and check all relevant sections to ensure full and accurate documentation. 9. Evaluation of the Home (Housing Assessment – if applicable) Required for requests related to residential repairs or identifying health/safety concerns in the home. The form must include: o Residential status o Client name and address o List of items needing repair The form must be signed and dated by the homeowner/tenant (if applicable) and the AAA staff completing the evaluation.

Categories

Internal Control / Segregation of Duties Eligibility Subrecipient Monitoring

Other Findings in this Audit

  • 571263 2023-005
    Significant Deficiency
  • 571264 2023-002
    Significant Deficiency
  • 571265 2023-003
    Significant Deficiency
  • 571266 2023-003
    Significant Deficiency
  • 571268 2023-004
    Significant Deficiency
  • 571269 2023-004
    Significant Deficiency
  • 571270 2023-005
    Significant Deficiency
  • 571271 2023-005
    Significant Deficiency
  • 571272 2023-005
    Significant Deficiency
  • 571273 2023-005
    Significant Deficiency
  • 571274 2023-005
    Significant Deficiency
  • 571275 2023-005
    Significant Deficiency
  • 571276 2023-005
    Significant Deficiency
  • 571277 2023-005
    Significant Deficiency
  • 571278 2023-005
    Significant Deficiency
  • 571279 2023-005
    Significant Deficiency
  • 571280 2023-005
    Significant Deficiency
  • 571281 2023-005
    Significant Deficiency
  • 1147705 2023-005
    Significant Deficiency
  • 1147706 2023-002
    Significant Deficiency
  • 1147707 2023-003
    Significant Deficiency
  • 1147708 2023-003
    Significant Deficiency
  • 1147709 2023-004
    Significant Deficiency
  • 1147710 2023-004
    Significant Deficiency
  • 1147711 2023-004
    Significant Deficiency
  • 1147712 2023-005
    Significant Deficiency
  • 1147713 2023-005
    Significant Deficiency
  • 1147714 2023-005
    Significant Deficiency
  • 1147715 2023-005
    Significant Deficiency
  • 1147716 2023-005
    Significant Deficiency
  • 1147717 2023-005
    Significant Deficiency
  • 1147718 2023-005
    Significant Deficiency
  • 1147719 2023-005
    Significant Deficiency
  • 1147720 2023-005
    Significant Deficiency
  • 1147721 2023-005
    Significant Deficiency
  • 1147722 2023-005
    Significant Deficiency
  • 1147723 2023-005
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.917 Hiv Care Formula Grants $3.96M
93.045 Special Programs for the Aging, Title Iii, Part C, Nutrition Services $1.42M
93.044 Special Programs for the Aging, Title Iii, Part B, Grants for Supportive Services and Senior Centers $1.04M
93.053 Nutrition Services Incentive Program $325,834
93.568 Low-Income Home Energy Assistance $289,161
93.052 National Family Caregiver Support, Title Iii, Part E $252,381
14.241 Housing Opportunities for Persons with Aids $167,026
93.499 Low Income Household Water Assistance Program $115,424
93.569 Community Services Block Grant $79,616
11.302 Economic Development Support for Planning Organizations $77,580
97.067 Homeland Security Grant Program $40,000
93.324 State Health Insurance Assistance Program $37,548
93.043 Special Programs for the Aging, Title Iii, Part D, Disease Prevention and Health Promotion Services $35,775
93.791 Money Follows the Person Rebalancing Demonstration $31,025
93.042 Special Programs for the Aging, Title Vii, Chapter 2, Long Term Care Ombudsman Services for Older Individuals $20,043
16.034 Coronavirus Emergency Supplemental Funding Program $14,800
93.071 Medicare Enrollment Assistance Program $12,900
93.048 Special Programs for the Aging, Title Iv, and Title Ii, Discretionary Projects $12,791
93.041 Special Programs for the Aging, Title Vii, Chapter 3, Programs for Prevention of Elder Abuse, Neglect, and Exploitation $4,431
93.072 Lifespan Respite Care Program $2,512
14.228 Community Development Block Grants/state's Program and Non-Entitlement Grants in Hawaii $1,393