SACRED HEART REHABILITATION CENTER, INC

Condition: It was noted during the audit the Center was using outdated forms provided by the pass through agency to document program eligibility related to income and insurance documentation. Criteria: The pass-through agency, Michigan Department of Health and Human Services, provides a form for subrecipients to use for "Declaration of Residency/No Income or Support/Insurance Eligibility" (Form MDHHS-5422). When updated, previous versions are obsolete per MDHHS. Cause: The Center does not have a process in place to check for form updates published on the MDHHS website and relies upon emails or other notifications. Effect: Client eligibility could be improperly assessed in accordance with pass-through entity's requirements and state-wide plan. Perspective: This is a systemic finding. Repeat Finding: This is not a repeat finding. Recommendation: Encourage Program Director to periodically check for updates to forms and schedules being utilized for updates and ensure all staff are utilizing the correct versions.

Although the updated MDHHS form 5522 has the same information as the outdated form, MDHHS was contacted to ensure Sacred Heart is on the state listserv to receive all MDHHS email updates and the program leader will contact the Contract Monitor prior to the start of the new contract year and search the website periodically to ensure there are no updates to forms. All updated forms will be distributed to case managers.

Condition: We noted two instances where household income was updated but the supporting documentation (ex: 1099s, paycheck stubs, etc) were missing from the files. Additionally, we noted one instance where household income was not updated but there was a current checkstub. In all instances, the client was in compliance with the poverty guidelines. Criteria: To be eligibile for services under the HIV program, clients must have income below 500% of the federal poverty level. Both the Federal and State levels of oversight require pass-through entities to have documentation of eligibility determinations and controls in place to ensure only eligible clients are receiving services. Cause: The Center does not have a program specifc checklist or file review to ensure all documentation is included in the files. Effect: Household income could be incorrectly calculated and ineligible clients could be receiving services. Perspective: The total population was 140 and 20 cases were examined. Three cases did not include supporting documentation. Repeat Finding: This is not a repeat finding. Recommendation: Consider creating a checklist that case managers are required to complete to ensure files are complete and all information is maintained. Consider having household income changes reviewed before services can be continued.

A checklist to ensure all files are completed and all information is maintained was developed. A review will be held after the reassessment, to ensure all required documentation is up to date and in the client file and in CAREWare.