Jefferson County Government

AUDITOR FINDING: 2025-001 Eligibility. We noted the following issues in the 25 cases tested: 1. One instance in which client income was incorrectly entered and as such, was ineligible for benefits as they were over the income limits for all of 2025. 2. Three instances in which, although case notes indicated general contact with the participant, the County did not retain sufficient documentation that a required meeting specifically addressed or confirmed engagement in an eligible work activity or was completed within required timeframe. Recommendation: We recommend that the County continue to strengthen internal controls related to eligibility determinations. This includes issuing training alerts related to the differences of subsidized and unsubsidized employment income and the impacts to eligibility. Additionally, we recommend continued periodic quality assurance reviews of TANF case files to ensure ongoing compliance with federal and state eligibility requirements and identification of employees with performance issues. Finally, we recommend the County develop monitoring reports to identify those clients who have not had a workforce contact in the required timeframe. CLIENT PLANNED ACTION: Jefferson County agrees with the findings and has taken or will take the following steps to address the errors. The findings were caused by workers on both the eligibility and workforce teams so varying measures will be implemented based on the finding and responsible team. Jefferson County will continue and implement the following actions to address and prevent future findings. • Eligibility Team Actions o Jefferson County will issue a training alert to all eligibility staff by June 20, 2026, detailing the difference between subsidized and unsubsidized employment, correct data entry, and the impact of each on TANF eligibility. o To monitor compliance, the County will continue completing Internal Quality Assurance reviews utilizing the state mandated list to assess the case and payment accuracy. • Workforce Development Team Actions o Performance concerns related to inconsistent client contact and incomplete documentation were identified during regular performance reviews in January 2026 and have been successfully addressed via the county Employee Relations coaching and disciplinary framework. •To monitor compliance, the County will continue completing Internal Quality Assurance reviews utilizing the state mandated list. In addition, Colorado Works Supervisors review at least one case per worker each month. Beginning in June 2026, the number will be increased to a minimum of 10 cases per month if a performance concern is identified. o Tableau reports have been created or enhanced to monitor compliance. • Individual case worker accuracy reports for all IQA and Supervisor reviews were released in March 2026. Progress reviews have been incorporated into monthly supervision meetings with staff. • Enhancement to report titled, Cases Needing Action, which tracks data entry of client contact and Individual Plan development in CBMS was completed on June 1, 2026. Workers will now be notified if client contact exceeds 30 days. Workers and supervisors will review the report monthly and take proactive measures for client contact prior to exceeding rule requirement of 90 days. CLIENT RESPONSIBLE PARTY: CW Eligibility Team: Julia Zoukhri (Program Manager), Brandy Brogan (Program Manager), Karen Thomas (Program Manager) and Jennifer Martinez (Quality Assurance & Systems Administrator) CW Workforce Development Team: Tara Noble (Program Manager), Kathryn Boyd-Cordova (CW Supervisor), and Erin Encinias (CW Supervisor) COMPLETION DATE: July 2026

Finding: Allowable Activities & Allowable Costs and Eligibility (Reference Number: 2024-001) Criteria or Specific Requirement: Funds may be expended for foster care maintenance payments on behalf of eligible children, in accordance with the Title IV-E agency’s foster care maintenance payment rate schedule and in accordance with 45 CFR section 1356.21, to individuals serving as foster family homes, to childcare institutions, or public/private child-placement or child-care agencies. In accordance with Code of Colorado Regulations (CCR) section 7.302.2, for each child, Jefferson County Human Services (JCHS) must have an agreement with the provider which details the daily maintenance payments. JCHS agreement to purchase services must be signed by the provider and JCHS. Additionally, in accordance with CCR section 7.301.3, the Family Services Plan shall be reviewed in conference with the caseworker and supervisor every 90 calendar days. Condition: • Two instances out of 40 where there was no signed agreement in place to support revised maintenance payments following a child’s 9th birthday. The correct maintenance amount was paid to the provider in accordance with the State of Colorado rates published in IM-CW–2024-0028 and IM-CW-2023-0021. • One instance out of 40 where the required 90-day review was not completed on time. The review was conducted 15 days late. Cause: The state's Foster Care system did not automatically generate a notice that a new agreement to purchase services was needed based on the child's birthday. Additionally, JCHS lacks an effective control mechanism to proactively identify when a 90-day review is approaching or overdue. Corrective Action Plan: We agree with the finding. The Integrated Case Management System (ICM) is designed to generate an email notification to Collaborative Foster Care Program (CFCP) staff when a child turns 9 or 14 years of age while in foster care. This email notification instructs CFCP staff to generate a new Child Specific Addendum (SS23-B) due to the increase of the child maintenance rate. This email instructs and standard procedure requires CFCP staff to verify the child maintenance rate in Trails after an SS23-B is generated. The IT Systems Support Team responsible for the maintenance of ICM determined that ICM has failed to notify CFCP staff when a child turned 9 or 14 years of age while in foster care: • The IT Systems Support Team responsible for the maintenance of ICM has been asked to ensure that ICM is generating an email notification when a child turns 9 or 14 years of age while in foster care. • While this issue is being addressed in ICM, the CFCP requested a report that included the birthdays for all children in foster care. CFCP staff have generated new Child Specific Addendums (SS23-B) for children that have turned 9 or 14 years old while in foster care. CFCP staff will utilize this report to generate new Child Specific Addendums for future birthdays. • After a new Child Specific Addendum is generated, staff will verify the child maintenance rate in Trails. • The CFCP has determined that it can no longer rely on ICM and has decided to migrate its functionality over to the ancillary system supported by Jefferson County known as the Caseworker Application Timesaver (CAT). With this migration, the email notifications will resume so that CFCP staff are properly notified of the need to generate the new SS23-B and verify the child maintenance rate. • Migration is scheduled to occur on Friday, June 20, 2025. • On Monday, June 23, 2025, the CFCP will meet with the Jefferson County Application Program Analyst to ensure the migration was successful. • Additionally, the CFCP and the Jefferson County Application Program Analyst have scheduled a second meeting for July 9, 2025, to ensure the successful migration from ICM to CAT. • To ensure 90-Day Reviews are completed timely, the Division of Children, Youth, Families, and Adult Protection (CYFAP) will continue to utilize the 90-Day Review compliance feature of CAT. Additionally, CYFAP leadership will emphasize this requirement with supervisors and casework staff and ensure their compliance. Person(s) Responsible for Implementation: Barb Weinstein, Director, Division of Children, Youth, Families and Adult Protection Implementation Date: July 1, 2025

FISCAL YEAR OF FINDING: 2023 AUDITOR FINDING: 1. At the time of the award – County did not make subrecipients aware of Federal Assistance Listing Number or title. 2. Risk Assessment could not be provided for 2022 or 2023 to support the level of monitoring. 3. Audited financials for family tree for 2022 or 2023 were not obtained by the County. 4. Family Tree did not have any case review monitoring performed during 2023 – October 15, 2022. Criteria: Condition: During testing, we noted the following: - The Assistance Listings number and Title were not provided to the County's two subrecipients in accordance with 2 CFR Part 200.332(a) - The County did not have a formal documented risk assessment completed for either of the County's two subrecipients in accordance with 2 CFR Part 200.332(b) - The County did not obtain or review one of the subrecipients single audit reports in accordance with 2 CFR Part 200.332(f) Effect: The subrecipient may be unaware whether the funds are federal or what compliance requirements they are responsible for. In addition, The County may not perform the adequate level of monitoring as formal risk assessments were not completed. Finaly, the County did not review the single audit report and while any finding would not directly be related to the subaward program, failure to review such reports and take appropriate action could result in non-compliance by the subrecipient continuing for an inappropriate length of time. Cause: The County does not have adequate internal controls over subrecipient monitoring to ensure that the County is in compliance with subrecipient monitoring requirements. Recommendation: We recommend that the County develop a risk assessment template or form to be completed over each federal subrecipient. The County should provide training to those administering grants over the development risk assessment template or form and the associated monitoring to be performed based on each assessed risk. In addition, the County should develop a subrecipient grant template to help ensure all required information is included within each award. Finally, the County should establish a policy or procedure over obtaining and reviewing audits completed over each of their subrecipients. CLIENT PLANNED ACTION: 1. On 4/8/24, Jefferson County sent the two ERA subrecipients the Federal Assistance Listing Number. The County policy is to include the Subaward Data Form, which includes the Federal Assistance Listing Number (see attached), as an Exhibit in all subrecipient contracts. This was inadvertently not included in the ERA contract. 2. On 4/8/24, Jefferson County completed a formal Risk Assessments for both The Action Center and Family Tree and placed in the files. The two subrecipients are long-time partners and federal fund recipients and have undergone continuous scrutiny through regular monitoring, and a rigorous draw reimbursement process. Due to this history and knowledge, both partners were determined to be very low risk at the time of ERA awards. Moving forward, the County will complete a formal Risk Assessment for the records prior to the execution of a contract or within 6 months of execution of a contract. 3. The County has now collected the audited financial statements for the two subrecipients and retained them in the files. Subrecipient audits are regularly reviewed as part of the monitoring process to assess for any findings or concerns. Moving forward, the County will obtain the most recent audit reports and place them in the files prior to the execution of a contract or within 6 months of execution of a contract. 4. The County performed a monitoring including the scrutiny of 20% of all case files during the 2022 ERA Program and there were no findings. The County had plans to monitor the ERA2 Program at the time of this audit, after the program was running at full capacity. The County has now moved up this time frame according to the above feedback and is currently undergoing a monitoring of the 2023 cases from the two subrecipients. This process aligns with the previous year, as the program has more time during the early spring months when cases are slower. Monitoring of subrecipients began the week of April 8th. CLIENT RESPONSIBLE PARTY: Kat Douglas, Community and Workforce Development Director COMPLETION DATE: 6/25/24

FISCAL YEAR OF FINDING: 2022 AUDITOR FINDING: 2022-005 Eligibility. We noted the following issues in the 40 cases tested: 1. Four instances in which income was incorrectly calculated based on information maintained in case file. 2. One instance in which there was inadequate documentation to support eligibility determination within the case file. 3. One instance in which the Colorado Works Referral form was not processed timely. 4. Two instances in which the County' eligibility authorization notes for the period selected did not agree to CHATS. Recommendation: We recommend that the County continue to strengthen the internal controls surrounding the eligibility process, specifically continuing the use and monitoring of case reviews to help identify potential areas for additional training. CLIENT PLANNED ACTION: Jefferson County agrees with the findings. There continues to be improvement each year in the overall findings, which demonstrates that the strategies previously implemented had the desired impact. However, the continued findings require additional action steps. Jefferson County will continue and implement the following actions to address and prevent future errors. ? The CCAP supervisor will continue reviewing available reports in CHATS to target untimely closures and follow up on potential erroneous case closures. Reports include the RE301, RE224, and RE115. Any case needing action will be assigned for completion within 5 business days and reviewed to ensure corrections were completed. ? Monthly case reviews will continue, at three levels, to assess case and payment accuracy. o The Jeffco Human Services Internal Quality Assurance (IQA) team will review 1% of the caseload monthly, utilizing the state mandated list. o The State Program Integrity Office will review cases monthly to monitor case and payment accuracy. o CCAP Supervisor and/or Lead Worker will review cases as follows: - The CCAP Supervisor will complete a minimum of two case reviews per worker per month. The number and type of review may be adjusted based on individual staff performance. Income and parent fee calculations will be targeted using the primary activity report in CHATS. The Lead Worker will fulfill this function if the Supervisor is out of the office. - 5% of all applications and redeterminations will be reviewed by the CCAP Supervisor or Lead Worker prior to approval. Jefferson County?s Internal Auditor has also been trained on the eligibility process and may review cases prior to approval to support the team. Eligibility Specialists will utilize a pre-authorization checklist when submitting the selected cases for review. The checklist was developed and implemented to assist workers in accurately entering and checking their data entry and eligibility determination. New CCAP Eligibility Specialists will have 100% of cases reviewed prior to approval until accuracy rates reach 95%, at which point preauthorization reviews will be reduced incrementally based on performance. o All responses to IQA or State Program Integrity regarding corrections or resolutions to cases will be documented and provided to the CCAP Supervisor/Program Manager within 2-5 business days, depending on the identified deadline, and will include screen shots verifying corrections prior to submittal. o Monthly meetings between the Division Director, Program Integrity Manager, Program Integrity Supervisor, Quality Assurance Supervisor, CCAP Program Manager, and CCAP Supervisor will continue in order to discuss performance and progress related to quality assurance and program integrity. Prior to the meeting, the Internal Quality Assurance (IQA) team will provide monthly reports for review and analysis. During the meetings, data and trends will be reviewed utilizing the aforementioned reports, which include error type, accuracy, and error increase/reduction over the year. In addition, training needs for staff will be discussed based on the supervisory, Internal Quality Assurance (IQA), and State level review findings and monitoring strategies will be developed to address areas of concern. ? Monthly review data is incorporated into all individual and leadership performance milestones. Milestones are the county?s employee performance management system. Continued errors or lack of progress and improvement will be addressed via the county Employee Relations coaching and disciplinary framework. ? Effective January 1, 2023, Jefferson County launched an updated model for service delivery and workload management utilizing an internal system, GenApp. The utilization of GenApp: o Improved document storage, o Increased oversight related to workload and timeliness as all pending actions can be viewed by type, date received and due date, o Simplified workload coverage due to employee leave or vacancies, o Removed inconsistencies in customer service, o Improved available reports. ? The Colorado Works Referral inbox has been prioritized by the CCAP Supervisor/Lead Worker for review and timely completion. ? Supplementary income training will be developed and delivered starting in October 2023 and continue on a quarterly basis to provide a review of income rules, calculation, common errors, and answer questions. CLIENT RESPONSIBLE PARTY: Tara Noble (Program Manager) and Monie Salgado (CCAP Supervisor) COMPLETION DATE: October 2023

2021-002

AUDITOR FINDING: 2022-006 Eligibility. We noted the following issues in the 25 cases tested: 1. One instance in which JCHS could not provide copy of the participant's Colorado Works Individualized Plan (IP), however case comments indicated an IP was completed. 2. One instance in which the Initial Assessment was not completed timely. 3. One instance in which JCHS did not properly cure the sanction after the client began complying with Colorado Works eligibility requirements. 4. One instance in which case comments were missing to support action of JCHS eligibility technician. CLIENT PLANNED ACTION: Jefferson County agrees with the findings and has taken or plans to take the following steps to address the errors. The findings were caused by workers on both the eligibility and workforce teams so varying measures will be implemented based on the finding and responsible team. Jefferson County will continue and implement the following actions to address and prevent future findings. ? Eligibility Team Actions o Beginning in August 2023, new processes were implemented for Colorado Works, which will improve timeliness, customer service, and increase staff program knowledge: - Prioritizing Colorado Works applications for interview scheduling within 3 business days, - Restructuring teams to create an intake and ongoing team to better meet timeliness measures, - Offering Colorado Works training in the fall of 2023, - Completed hiring for all vacant positions. o Additional training will be provided by the end of October 2023 to include: - Continue to emphasize the importance of clearing the compliance screen in CBMS when processing new applications during new worker training, - Providing a training alert requiring that all staff who process Colorado Works cases check the compliance screen as part of the intake process, - Provide coaching to the eligibility worker who processed the case. o The sanction that was improperly advanced was reversed and appropriate case note entered on August 31, 2023. ? Workforce Development Team Actions o In addition to the State and Internal Quality Assurance reviews, Colorado Works Supervisors and/or Lead Workers will review cases as follows: - Complete a minimum of two case reviews per worker per month. The number and type of review may be adjusted based on individual staff performance. The Lead Worker will fulfill this function if the Supervisor is out of the office or as needed to the team. Areas of focus will include but are not limited to timely case comments, active Individual Plans, and CBMS data entry. o Updated standards implemented in July 2022 requiring documents be uploaded into the document storage system, GenApp, within 7 days. o Training delivered during new employee onboarding and starting in May 2023, offered on a quarterly basis for document uploading and best practices. o Finding related to missing case note was corrected on August 23, 2023. CLIENT RESPONSIBLE PARTY: CW Eligibility Team: Amy Brown (Program Manager), Stephanie Reese (Program Manager) and Jennifer Martinez (Quality Assurance & Systems Administrator) CW Workforce Development Team: Tara Noble (Program Manager), Kathryn Boyd-Cordova (CW Supervisor), and Erin Encinias (CW Supervisor) COMPLETION DATE: September 2023

2021-002 Passed-through Colorado Department of Human Services CFDA 93.575 and 93.596 ? all grants Child Care and Development Block Grant and Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster) Allowable Costs and Allowable Activities Eligibility Material Non-Compliance Material Weakness in Internal Control over Compliance Condition: We tested eligibility and allowable costs and activities for 53 eligibility cases. We noted the following in our testing: ? 5 instances of non-compliance in which income was calculated incorrectly by the case worker. As part of eligibility determination, the income was incorrectly calculated based on information maintained in case file. As a result of this, the corresponding parent fee was also incorrectly determined. ? 3 instances of non-compliance in which cases were not closed in a timely manner and in accordance with State rules & regulations. ? 1 instance of non-compliance in which the parent fee was not attached to the case in the CHATS system. This caused federal dollars to cover all the care charges in the month rather than the beneficiary paying their responsible portion of childcare and federal dollars covering the remainder. ? 1 instance of non-compliance in which there was inadequate documentation to support income within the case file. ? 1 instance of non-compliance in which the parent fee was not able to be recalculated based on support included in the case file. Corrective Action Plan: Jefferson County agrees with these findings. While there has been improvement each year in the overall findings, additional strategies are required to manage, evaluate, and strengthen the compliance and monitoring of the Child-Care Assistance Program (CCAP). Timing is a factor in some case findings as the period under review was prior to the implementation of the corrective action plans. However, several data points and assessments demonstrate that the strategies implemented throughout 2021 had the desired impact on the areas of concern, including a decrease in this audit?s findings from the previous year, current internal quality assurance reviews show significant improvement in both accuracy and timeliness. Additionally, the State ended monthly monitoring meetings with leadership citing the satisfaction of recommendations related to implementing procedures for data entry verification, increasing quality assurance reviews, and utilizing CHATS reports to resolve outstanding recoveries. The continuous findings are cause for concern and require continued adherence to effective monitoring and management practices and the implementation of additional mitigation efforts. In addition to the strategies already implemented from previous corrective action plans, the following actions will be implemented or revised to address and prevent future errors: ? To address compliance related to timely case closures, the Supervisor will review the pending report available in CHATS (RE301) on a weekly basis to identify and follow up on case closures. ? Case reviews will continue, at three levels, on a monthly basis to assess case and payment accuracy. o The Jeffco Human Services Internal Quality Assurance (IQA) team reviews 1% of the caseload monthly, pulling from the state list and adding cases as needed to include a sample from all workers. o The State Program Integrity Office reviews a random pull of cases monthly beginning July 2022. o The CCCAP Supervisor conducts a combination of progressive, targeted and full case reviews, following up with individual and team training as needed. The number and type of review may be adjusted based on trend data and business needs. The Lead Worker will fulfill this function while the Supervisor is out of the office. Due to staffing shortages, the Jeffco Human Services Internal Quality Assurance team pulled additional cases through August 2022 to meet this action item. ? The CCCAP Supervisor will utilize the primary activity report available in CHATS to identify at least one case per worker with income and review income and parent fee calculations. ? To address the parent fee attachment error, effective March 20, 2022, CHATS functionality includes an alert on the parental fee screen, noting any discrepancies. The discrepancy must be addressed to move forward with processing the case, reducing the risk for this error. Responsible Individuals: Program Manager Tara Noble, Interim CCAP Supervisor Brenda Bouchard, and CCAP Supervisor Monie Salgado Anticipated Completion Date: ? CHATS report RE301 will be pulled weekly for review beginning August 29, 2022. ? Monthly case reviews and responses will continue with the following updated methods and timelines: o Jeffco HS Internal QA returns to reviewing 1% of the caseload monthly beginning September 1, 2022. o State Program Integrity will review cases as requested via random pull. o CCAP Supervisor or Lead Worker will review cases as follows: ? Beginning September 1, 2022, at least 2 cases per worker will be reviewed for timeliness and accuracy. Income and parent fee calculations will be targeted using the primary activity report in CHATS. ? Beginning October 1, 2022, 5% of all applications and redeterminations will be reviewed prior to approval and as outlined in the State Corrective Action Plan. The delay in implementation of this action item was due to staffing shortages experienced since November 2021. o All responses to IQA or State Program Integrity regarding corrections or resolutions to cases will be documented and provided to the CCAP Supervisor/Program Manager within 2-5 business days, depending on the identified deadline, and will screen shots verifying corrections prior to submittal. Beginning in October 2021, monthly meetings between the Division Director, Program Integrity Manager, Quality Assurance Supervisor, CCAP Program Manager and CCAP (Interim) Supervisor were held to review data and trends and develop strategies to address areas of concern. These meetings will continue through December 2022, thereafter, the frequency will be re-evaluated based on progress and program needs. o In August 2021, State CCCAP held monthly monitoring meetings with leadership, and transitioned to every other month in March 2022, to review progress related to areas of non-compliance identified in the CCCAP Management evaluation conducted in May 2021. ? In 2022, monthly review data was incorporated into all individual and leadership performance milestones. Milestones are the county?s employee performance management system. Continued errors or lack of progress and improvement will be addressed via the county Employee Relations coaching and disciplinary framework. ? Training Improvements o In November 2021, a training plan was created and implemented for new hires, including policies/procedures, tools, state reference guides and rule citations for different stages of the eligibility determination and management processes. o In the first quarter of 2023, we will incorporate CCAP training into the Community Assistance Division Training Team to provide new employee CCAP training as well as regular training for all existing employees, utilizing monthly case review data to inform training needs. Sincerely, Tara Noble, Human Services Program Manager

2020-002

2021-003 Passed-through Colorado Department of Human Services Federal Financial Assistance Listing/CFDA Number 93.659 ? All Grants Adoption Assistance Title IV-E Allowable Costs and Allowable Activities Significant Deficiency in Internal Control over Compliance Criteria: The Adoption Assistance program provides federal matching funds to eligible Title IV-E agencies that provide ongoing subsidy and/or nonrecurring payments to parents who adopt eligible children. There are compliance requirements regarding allowable costs and allowable activities to ensure federal funds are expended in accordance with a written and binding adoption assistance agreement. Furthermore, the Uniform Guidance, Section 200.303 Internal Controls, requires that the non-Federal entity must establish and maintain documentation of effective internal controls over Federal awards that provide reasonable assurance that awards are being managed in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. Condition: We tested allowable costs and activities for 60 adoption subsidy payments. We noted the following in our testing: ? One instance in which the adoption subsidy payment was incorrectly calculated based on the signed contract maintained with the file. Cause: The County?s controls failed to ensure the program?s allowable costs and activities criteria were met. Effect: The error resulted in an incorrect subsidy payment distributed to the adopted parents. Questioned Costs: None to report Context/Sampling: A nonstatistical sample of 60 participants out of 10,386 were selected for allowable cost testing. Repeat Finding from Prior Year(s): No Recommendation: We recommend the County implement controls which include a review of rates entered in the system to the signed contracts to ensure accurate subsidy payments. Views of Responsible Officials: AgreeResponsible Individuals: Roxanne Sabin, Program Manager Madison Bright, Supervisor Corrective Action Plan: In March 2022, Supervisor Bright implemented a process of using the county developed and owned Child Welfare Application Timesaver system to review and confirm that the subsidy amount entered in the Comprehensive Child Welfare Information System (CCWIS) matches the amount in the signed contract before approving it for processing. Anticipated Completion Date: Ongoing

2021-004 Passed-through Colorado Department of Labor and Employment Federal Financial Assistance Listing/CFDA Number 17.277 ? All Grants Emergency Recovery Grant WIOA DW Disaster Recovery Grant WIOA DW Reporting Significant Deficiency in Internal Controls over Compliance Criteria: The Emergency Recovery and Disaster Recovery programs provide federal funds to eligible dislocated workers to minimize the economic impact on individuals whose jobs have been impacted by the COVID-19 pandemic. There are compliance requirements regarding reporting to ensure federal funds are being expended in accordance with the grant agreements. Furthermore, the Uniform Guidance, Section 200.303 Internal Controls, requires that the non-Federal entity must establish and maintain documentation of effective internal controls over Federal awards that provide reasonable assurance that awards are being managed in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. Condition: We tested reporting for three reports required to be submitted to the State. We noted the following in our testing: ? All three instances in which there was no documentation of review and approval of the reports by management before they were submitted to the State. ? One instance where the required report was not submitted timely. ? One instance where the amounts reported were not supported by the County?s records. Cause: The County failed to ensure the internal controls surrounding compliance over the program?s reporting criteria was met. Effect: Documented approvals, untimely and/or inaccurate submission of reports to the State. Questioned Costs: None to report Context/Sampling: A nonstatistical sample of 3 reports out of 16 were selected for reporting testing. Repeat Finding from Prior Year(s): No Recommendation: We recommend the County implement controls which include a review of reports required to be submitted to the State to documented approvals, timely and accurate completion and submission of all required reporting documents. Views of Responsible Officials: Agree. Responsible Individuals: Amanda Hoffa, Program Manager Lisa Kukreja, Supervisor Corrective Action Plan: As the program was being implemented local areas and CDLE were identifying processes while providing services. Some tracking tools, mechanisms and procedures were revised accordingly as issues were identified. All issues were resolved and reported accurately to CDLE. While all reports were reviewed by the program manager prior to submission to the state, new processes were implemented (prior to the audit) to capture the approvals electronically and store the approvals for future reference. Additionally, several elements in the reports that generated this audit finding of `significant deficiency? have not been required since May 2021. CDLE only requires the quarterly narrative reporting and ceased requiring enrollment and fiscal reporting by local areas. All customer enrollment information is stored in Connecting Colorado (statewide Labor Exchange and case management system) and all fiscal information is stored in the CLEAR state financial system. Since May 2021 the state relies on these two systems for this information. Anticipated Completion Date: Ongoing

Jefferson County Summary of CY findings December 31, 2020 2020-002 Passed-through Colorado Department of Human Services Federal Financial Assistance Listing/CFDA Numbers ? All Grants 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster) Allowable Costs and Allowable Activities Eligibility Material Non-Compliance Material Weakness in Internal Control over Compliance Finding Summary: Condition: Eligibility and allowable costs and activities were tested for 54 eligibility cases. We also tested 26 Quality Assurance (QA) reviews. The following was noted in the testing: ? 16 instances of non-compliance in which income was calculated incorrectly by the case worker. As part of eligibility determination, the income was incorrectly calculated based on information maintained in the case file. ? 14 instances in which the parent fee was incorrectly determined based on information maintained in the case file. ? 2 instances in which the parent fee was incorrectly determined due to a CHATS system error placing a participant in the incorrect federal poverty guideline. ? 2 instances of non-compliance in which the parent fee was not attached to the case in the CHAT?s system. This caused federal dollars to cover all care charges in the month while the beneficiary was not charged for their portion of childcare. ? 2 instances where a QA case review was performed and a finding was noted due to missing signature(s) on application; however, the review finding was not corrected. This did not result in a change of eligibility. Corrective Action Plan: We agree with these findings. In addition to the pandemic related workload, the program also faced challenges with internal controls, inconsistent practices and limited overall performance data. For example, a more consistent and thorough process was needed to resolve/rebut findings, including prevention strategies and confirmation of corrections. To address these challenges and improve program integrity, we are addressing multiple action items identified in the state?s County Site Visit, connecting with other counties for best practices. Secondly, timing was a factor for the level of findings. Due to the timing of the Corrective Action Plan, state training, case review eligibility period and 2020 audit, there was limited time to implement the strategies and assess the impact of the plan. For example, many the findings were associated with eligibility determination dates prior to the Corrective Action Plan submission in June 2020. Of the 16 income calculation errors, 7 cases were processed in 2019. Thirteen (13) of the 16 cases were processed prior to the availability of state training and reference tools in April 2020. However, the results of the upcoming county audit are anticipated to be improved, based on results from the 128 case reviews conducted in 2021 by the Jeffco Human Services internal Quality Assurance team, CCCAP Supervisor, state Economic Assistance Quality Assurance (EAQA) and the state County Site Visit. In addition to the items in the Corrective Action Plan, we have implemented the following internal control and monitoring processes, based on data, assessed needs and technical assistance from the state. ? To augment the Income Calculation Tool, Eligibility Specialists are required to use the case comment template to document information supporting the calculations and other actions on the case. ? Team members are required to attend periodic state meetings, such as the CHATS User Group, for updates, and technical assistance. Further guidance is provided during CCCAP team meetings and email correspondence. ? Case reviews are conducted at three levels on a monthly basis to assess case and payment accuracy. ? The Jeffco Human Services internal Quality Assurance team reviews 1% of the caseload monthly, pulling from the state list and adding cases as needed to include a sample from all workers. ? The State EAQA Office typically reviews a minimum of one case per month. ? The CCCAP Supervisor conducts a combination of progressive, targeted and full case reviews, following up with individual and team training as needed. The number and type of review may be adjusted based on trend data and business needs. The Lead Worker will fulfill this function while the Supervisor is out of the office. ? The newly developed State CCCAP County Review Framework has been implemented for internal and state reviews, strengthening consistency, inter-reviewer reliability and program integrity. ? Beginning in 2021, all case reviews will be tracked, analyzed and reported, using the Case Review Repository, as a more comprehensive assessment of performance and trends. ? Increasing the level of oversight, the Program Manager will manage the CCCAP quality assurance process including: 1) analyzing and reporting data on the case review results; 2) monitoring status of identified action items; 2) meeting with the CCCAP Team monthly to discuss trends and training needs; 3) checking internal/external case review responses prior to submission; and 4) convening monthly meetings with IQA and designated Human Services leadership to discuss trends, root causes and strategies to address findings. ? To ensure errors have been addressed, the Eligibility Specialist and Supervisor prepare the response, noting the appropriate action, including correction, resolution, rebuttal and prevention strategy. If it?s a rebuttal, the corresponding rule citation or reference needs to be included. Corrections of all findings are confirmed by the Supervisor or Program Manager and noted in the corresponding case review response form. ? Addressing the parent fee attachment error, CHATS functionality now includes an alert on the parental fee screen, noting any discrepancies. The discrepancy must be addressed to move forward with processing the case, reducing the risk for this error. Responsible Individuals: Program Manager Dani Crane and CCCAP Program Supervisor Margie Morris Anticipated Completion Date In addition to the practices described above, the following actions will be implemented. ? The identified action items will be completed by August 24, 2021, as part of the formal response to the state?s County Site Visit. ? As part of this response, a formal process will be submitted, outlining the step-by step process for eligibility determination. The document will incorporate corresponding rule citations and information from the state?s Quick Reference Guides. ? Effective August 2021, Eligibility Specialists will automatically be required to re-take the state self-paced ?CCCAP Income? module when receiving an income calculation finding in a county or state case review. ? The Case Review Repository will be updated monthly, with reports provided to Human Services leadership and CCCAP Team. ? The findings related to CHATS database, were addressed through a state system release on September 29, 2019. Sincerely, Dani Crane, Program Manager Human Services

2019-002

Finding: 2020-003 Federal Agency Name: Passed-through Colorado Department of Public Health and Environment Program Name: Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Federal Financial Assistance Listing/CFDA Number: 10.557 ? All grants Finding Summary: There are various eligibility requirements for WIC detailed in the Uniform Guidance. Under the eligibility compliance requirement, guidance requires a competent professional authority must determine that the applicant is at nutritional risk. Further noted in the Colorado WIC Program Policies and Procedures, when a participant is diagnosed as high risk, they must have an appointment with a WIC Counselor within one month of the eligibility determination. The participant shall be granted one month of food benefits during the timeframe until counseling session has occurred. Additionally, the Uniform Guidance, Section 200.303 Internal Controls, requires that the non-Federal entity must establish and maintain documentation of effective internal controls over Federal awards that provide reasonable assurance that awards are being managed in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. The auditors tested eligibility and allowable costs and activities for sixty eligibility cases. The following was noted in their testing: ? 4 instances of which high risk participants were granted more than one month of benefits prior to receiving a nutritional counseling session by a competent professional authority. ? 60 instances in which no control over eligibility determination was identified or documented. Responsible Individuals: Kylie Harrison, MS, RD, CLC ? Community Nutrition Manager Corrective Action Plans: The Jefferson County Public Health WIC Program would like to acknowledge the audit findings from November of 2020 and make it known that the findings occurred because of the global pandemic and massive changes that occurred to the WIC Program because of this pandemic. The control over eligibility determination has been in place prior to 2020 through staff chart audits. These audits have taken place at minimum twice per year and has prevented any audit findings in the past. Unfortunately, with the timing and the events of the pandemic, these audits were postponed and did not occur until the end of 2020, making it impossible to demonstrate the controls we have had in place over the years. To prevent this situation from happening in the future and to have more frequent spot checks in place, tightening our controls, each supervisor will complete monthly chart reviews for their staff that complete eligibility determinations. Finally, to ensure we have completed the necessary high-risk counseling within one month of the determination of a high-risk factor for our participants, we will run a high-risk nutrition education report monthly. This report will allow us to review that all participants have received a nutrition education contact from a Registered Dietitian and/or that there is documentation of the attempted contact. Anticipated Completion Date: January 1, 2021

Finding 2019-002 Passed-through Colorado Department of Human Services CCDF Cluster CFDA #93.575 and 93.596 Allowable Costs and Allowable Activities Eligibility Material Non-Compliance Material Weakness in Internal Control over Compliance Finding Summary: Condition: We tested eligibility and allowable costs and activities. We noted the following in our testing: ? 13 instances of non-compliance in which income was calculated incorrectly by the case worker. As part of eligibility determination, there income was incorrectly calculated based on information maintained in case file. ? 15 instances in which the parent fee was incorrectly determined based on information maintained in case file. ? 5 instances of non-compliance in which the parent fee was not attached to the case in the CHAT?s system. This caused federal dollars to cover all of the care charges in the month rather than the beneficiary paying their responsible portion of child care and federal dollars covering the remainder. ? 4 instances of non-compliance in which the County failed to obtain a complete application, which also includes the client responsibilities agreement. In each instance, the application did not have the appropriate signature page signed by applicant, rendering the application incomplete. ? 7 instances of non-compliance in which the parent fee was not calculated correctly. This error was identified by the State that the CHATS system was experiencing glitches resulting in rounding errors. The issue was identified, but if the parent fee required an increase to correct the rounding error, this was not possible until the redetermination date. Corrective Action Plan: We agree with these findings. In 2019, the CCAP program was impacted by changes in personnel, regulations, processes and the CHATS system. As such, employee training, internal controls and consistent practices were negatively affected. Moving forward, we are working closely with the state?s Office of Early Childhood, to address identified issues, supporting the following strategies: ? Eligibility staff will attend State CCAP training to revisit program regulatory requirements. ? To mitigate risks and apply consistency in calculating household income, staff will be required to incorporate the State approved ?income calculation form? in all case files. ? CCAP Program Supervisor will work collaboratively with County QA team to ensure findings are consistent with supervisor case reviews, and to identify trends for any additional ongoing training needs. ? On a monthly basis, the CCAP Supervisor will review internal/state case audit results with eligibility specialists and lead worker, identifying trends and training needs. Results are incorporated into individual and program performance measurement. ? Protocols for communicating policy/processes will be improved through weekly team huddles and email correspondence. The supervisor and lead worker will vet questions/updates, ensuring consistent messages are shared with team members. Responsible Individuals: Program Manager Dani Crane and CCAP Program Supervisor Margie Morris Anticipated Completion Date: ? The supervisor, lead worker and eligibility staff completed 24 hours of state CCAP training on May 7, 2020. ? CHATS database issues were fixed in 2019, addressing rounding errors. ? Re-occurring monthly joint meetings scheduled with County QA team, effective June 18, 2020. ? Improved communication protocols were implemented by April 30, 2020. Sincerely, Dani Crane, Program Manager Human Services

Finding 2019-003 Passed-through Colorado Department of Labor CFDA #17.258, 17.259, 17.278 WIOA Cluster Program Allowable Costs and Allowable Activities Significant Deficiency in Internal Control over Compliance Finding Summary: Condition: We tested allowable costs and controls over participant payments charged to the WIOA cluster for sixty case files. Testing included ensuring that costs charged to the program were approved, properly supported and charged to the appropriate grant. We noted the following errors in our testing: ? Two instances in which the County incorrectly charged costs to the WIOA dislocated Worker Program (CFDA #17.278) that were incurred for a participant in the WIOA Adult Program (CFDA #17.258). Corrective Action Plan: In one of the instances referenced above, the Human Services Business & Finance office inadvertently transposed numbers and coded incorrectly the business unit to be charged after WIOA program staff had reflected the appropriate coding. In the second instance, WIOA program staff indicated the incorrect business unit on the distribution ticket, which was charged accordingly. Remedies instituted by the WIOA program staff include closer scrutiny of distribution tickets by approving supervisor as well as by quality assurance to ensure customer costs are charged to the WIOA program of enrollment. Fiscal reviews of random transactions are now being performed by quality assurance on a quarterly basis, as opposed to the previous practice of fiscal reviews at time of exit from the program. Human Services business and finance accounts receivable staff review all the cash equivalent disbursement tickets when initially received. The account number and client ID is entered into a spreadsheet that is reviewed by a second staff member. The account technicians in the Human Services business and finance office prepare a journal entry using the spreadsheets provided by the AR group. An accountant then reviews the final journal entry and the supervisor approves the final entry. Responsible Individuals: Susan Rumley as supervisor of quality assurance team for Community & Workforce Development Division. Patty Myers and Bobbie Cook, supervisors of Human Service Business and Finance Office. Anticipated Completion Date: Adjusting journals were initiated at the time of discovery for these transactions. Quarterly fiscal reviews of active customer files by WIOA program quality assurance began in 2020. Sincerely, Susan Rumley, Community & Workforce Dev Asst Director

Finding 2019-004 Passed-through Colorado Department of Human Services CFDA #93.563 Child Support Enforcement Allowable Costs and Allowable Activities Significant Deficiency in Internal Control over Compliance Finding Summary: Condition: We tested 68 program expenditures verifying compliance requirements and controls were in place. We noted the following in our testing: ? One instance in which there was no approval for an expenditure. ? One instance in which an expenditure was incorrectly allocated to the program and included expenditures from 2018 in the allocation calculation. Cause: Due to ineffective monitoring, the County was unable to provide the appropriate documentation of an approval. County also incorrectly allocated expenditures to the program. Effect: Failure to review and approve expenditures as well as incorrectly allocating expenditures could result in unallowable costs being charged to the grant ? Corrective Action Plan: There are currently processes in place that require authorized signature approvers to assign account information and to sign the invoice or approve by email. The accounting supervisor will train the technicians on the required process to ensure all invoices have an authorized signature. ? The immaterial amounts for 2018 expenditures charged to the program were undercharged in 2018 due to new employees assigned to those responsibilities. The Jefferson County Finance Department has subsequently put processes in place to capture these and similar allocations. The Sr. Accounting Supervisor has continued to train and work with new finance accounting staff to ensure allocations are made in the correct year. Responsible Individuals: Program Manager Saadia Aurakzai-Foster Anticipated Completion Date: 07/31/2020 Sincerely, Saadia Aurakzai-Foster

Finding 2019-005 Passed-through Colorado Department of Human Services Passed through Larimer County CFDA #93.558 Temporary Assistance for Needy Families (TANF Cluster) Allowable Costs and Allowable Activities Significant Deficiency in Internal Control over Compliance Finding Summary: Condition: We tested 65 administrative transactions, of which 60 related to timesheets for which employees charged time to the TANF grant. We noted the following in our testing: ? Three timesheets did not indicate that supervisors approved the staff?s timesheet Corrective Action Plan: We agree with this finding. Due to human error, three timesheets in the county?s electronic timecard system were not approved by a supervisor. Additional training has been provided to supervisors, including emphasizing the expectation for approving timesheets and establishing delegates when out of the office. This training will be provided annually, referencing the online step-by-step online guidance. Supervisors will review/approve timesheets by the Tuesday afternoon following each payroll period. To ensure compliance, the Program Manager will review approvals, using the delegation function in Kronos for each payroll period. Responsible Individuals: Program Manager Dani Crane and Associate Director Michelle Cornett Anticipated Completion Date: The timesheet approval roster is reviewed on an ongoing basis and the next annual training will be conducted in July, 2020. Dani Crane, Program Manager Human Services

Finding 2019-006 Passed-through Colorado Department of Human Services CFDA #93.558 Temporary Assistance for Needy Families (TANF Cluster) Eligibility and Special Tests Significant Deficiency in Internal Control over Compliance Finding Summary: Condition: We tested sixty eligibility cases for which EB verified documentation of income verification. We also tested forty Quality Assurance (QA) reviews. We noted the following in our testing: ? Two instances where IEVS documented a change in income; the changes were not addressed within the 45-day requirement. This did not result in a change in eligibility. ? One instance where a case review was performed by the Quality Control department; however, the review finding as not corrected. This did not result in a change in eligibility. Cause: Due to insufficient controls over the IEVS process, controls are not operating as designed to prevent, detect and correct errors timely. Due to insufficient monitoring over the QA process, errors remained uncorrected. Effect: Failure to monitor IEVS reported changes could result in ineligible participants receiving benefits. Similarly, failure to correct errors identified in the QA process could also result in incorrect eligibility determinations. Corrective Action Plan: 1. Our reports team will continue to prioritize the monthly IEVS report. Additionally, we will continue to have individual staff discussions related to clearing IEVS when they are working cases. The expectation is staff will clear IEVS as they work a case. 2. Cases with incorrect IEVS action will be identified and addressed through our current Supervisor Case Review process. Supervisors are expected to review three cases each month for every staff member with full authorization. 3. Program Managers will enforce and Supervisors will be held accountable to, the existing Quality Assurance procedure which states ?Program Supervisors will receive and review findings with the Program Specialist to ensure all correction are made. All corrections and rebuttals must be submitted within five business days.? Responsible Individuals: EMAS ? Pamela Olesen and Alissa M. Trumbull - Program Managers LTC ? Karin Stewart, Program Manager Anticipated Completion Date: Corrective Action Plans are currently in place and being evaluated on an ongoing basis. Sincerely, Dani Crane, Manager Human Service Programs

Finding 2019-007 Passed-through Colorado Department of Health Care Policy and Financing CFDA #93.778 Medical Assistance Program (Medicaid Cluster) Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: Condition: We tested eligibility determination and controls over this process for sixty case files. We noted the following in our testing: ? Two instances of non-compliance in which the County did not complete the eligibility determination and approve/deny the case within 45 days. The case was not authorized by the caseworker and no notice of action was sent to the client within the required timeframe. ? One instance of non-compliance in which the County failed to provide proof of the client?s application. We obtained other supporting documentation to provide assurance that the client did in fact apply for Medicaid in order to be eligible to receive benefits. ? Three instances in which a case review was performed by the Quality Control department; however, the review findings were not corrected. This did not result in a change in eligibility. Corrective Action Plan: Exercising tangible controls will continue to improve the above sited non-compliances and improve the integrity of issuing Medicaid benefits. 1. The State EPG report through Tableau is monitored daily by supervisors and program managers. We have enhanced data points in Tableau to include the number of cases untimely, currently timeliness percentage and the number of cases needed to raise our timeliness percentage to meet programmatic goals. Additionally, we are also using GenApp data to ensure we are processing what is due sequentially. 2. GenApp, our work-flow management system, has allowed us to integrate scanning and data tracking for all incoming tasks and related documents enabling Supervisors to appropriately prioritize and assign work and resources. We have recently implemented GenApp V2 with additional reporting and tracking capabilities to assist our teams with monitoring timeliness and workload. 3. Program Managers will enforce and Supervisors will be held accountable to the existing Quality Assurance procedure which states ?Program Supervisors will receive and review findings with the Program Specialist to ensure all correction are made. All corrections and rebuttals must be submitted within five business days.? Responsible Individuals: EMAS ? Pamela Olesen and Alissa M. Trumbull - Program Managers LTC ? Karin Stewart, Program Manager Anticipated Completion Date: Corrective Action Plans are currently in place and being evaluated on an ongoing basis. Sincerely, Pamela Olesen, Program Manager Human Services

2018-004

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2017-001

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2014-002

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