10.1 Effective Internal Controls

Lead Agencies must ensure the integrity of the use of CCDF funds through effective fiscal management and must ensure that financial practices are in place. Lead Agencies must have effective fiscal management practices in place for all CCDF expenditures. 10.1.1 Organizational structure to support integrity and internal controls Describe how the Lead Agency’s organizational structure ensures the oversight and implementation of effective internal controls that promote and support program integrity and accountability. Describe: The Lead Agency’s organizational structure ensures the oversight and implementation of effective internal controls that promote and support program integrity and accountability by including multiple departments in the program integrity work. A bi-weekly program quality and compliance meeting brings together cross program administrators, IT and operations leads, legal, and financial management who have authority and responsibility for program integrity activities within their departments. Delegation of duties resides with each lead. For example, the Assistant Director for the Office of Child Care and the CCAP Administrator assign integrity related tasks within program staff, including CCAP case review, provider monitoring and systems incident reporting and solutioning. Fiscal and program staff meet continuously with formal meetings scheduled weekly at the leadership level and at the implementation level. Provider Management’s focus is on enrollment and provider data accuracy. Financial management’s focus in on billing and payment accuracy. The two teams review bi-weekly batch payment reports to solution children reported ineligible and to ensure accurate provider payments including number of records processed, amounts for Union, PAC, and family co-share amounts. This information is validated across an average of the last ten batches. Program and IT meet weekly to identify and solution systems issues related to accurate eligibility determinations and accurate reimbursement rate application and payment. Operations and financial team members and the newly appointed administrator for program quality attend this meeting as well. In terms of checks and balances within the child care system, we have two very specific divisions within the office, program and finance, that work together on all things finance. The two teams collaborate on a Provider Monitoring project where program collects parent-providers agreements and attendance documentation from providers and reviews enrollments, and financial management reviews payments for specified batch periods for accuracy based on documentation and enrollment. In this process, the program and financial management leads conduct randomized internal audits of approximately a dozen CCAP provider monthly, asking for attendance records for specific batch periods for 40% of the CCAP children. The Department uses this information to provide mandatory technical assistance and training and will work with providers to streamline procedures to ensure accurate payment records. This monitoring is looked at from both a program lens and a financial management lens separately and then together. Results are provided to the child care program and the goal is to get to every provider through a 3- year cycle. For grants and contracts, invoice approvals occur in both finance and program as well. Program staff will check invoices for allowable costs, while finance will check invoices for alignment to budget. Additionally, the Office of Internal Audits (OIA) is a partner is collaborating on effectiveness of both financial and operational controls. As required by ACF, the Lead Agency conducts case reviews to identify improper payments on a three-year cycle. The Lead Agency has implemented ongoing reviews beyond the end of the current cycle to continue through June 2025 to ensure continued identification of errors and to inform ongoing accuracy in eligibility and payments. The Provider monitoring results are reviewed at two levels as a check and balance on determination of compliance with policies or potential for fraud risk. The provider management team and the financial management team review the information provided from a program and fiscal lens. Include the following elements in your description: 1. Assignment of authority and responsibilities related to program integrity. 2. Delegation of duties. 3. Coordination of activities. 4. Communication between fiscal and program staff. 5. Segregation of duties. 6. Establishment of checks and balances to identify potential fraud risks. 7. Other activities that support program integrity. 10.1.2 Fiscal management practices Describe how the Lead Agency ensures effective fiscal management practices for all CCDF expenditures, including: a. Fiscal oversight of CCDF funds, including grants and contracts. Describe: The Grants Management Office is responsible for managing applications for federal funding, providing administrative support to state agencies regarding reporting requirements, providing technical assistance related to the Grants Management System and approving agreements with federal agencies. The Grants Management office has implemented a Grants Management System (GMS) which programs are required to use to execute contracts, process invoices and track spending. This system has standardized and streamlined processes around the federal award process. The Department employs Programming Services Officers overseen by the Assistant Director to manage contract development, deployment, and compliance. The PSO maintains continuous performance and fiscal oversight of the contracted partner from initial scope development through final deliverables and end of contract term. They monitor to ensure contracts comply with CCDF regulations, that partners adhere to approved budgets and that measurable outcomes are met and reported. PSOs work with fiscal staff to ensure costs align with deliverables and invoices reflect allowable expenses per the terms of the contract and regulatory requirements. Fiscal staff is responsible for sub-recipient monitoring as well as monitoring all grant expenditures. Fiscal staff also submit financial quarterly reporting, which ties to the State financial systems. In terms of CCDF funding not expended through grants and contract, the Department issues certificates for child care subsidies to eligible families based on our CCAP regulations. At that time, a CCAP-approved provider will enroll a child based on the certificate number provided by the family. Our Bridges system generates attendance records, and the providers are required to fill out the record based on the service dates that the child was in attendance. The submitted attendance records are approved and reviewed by the data clerks at the Child Care Payment office. Upon approval, bi-weekly payments are generated based on a cross check of child care eligibility to the attendance reports that are submitted. b. Tracking systems that ensure reasonable and allowable costs and allow for tracing of funds to a level of expenditure adequate to establish that such funds have not been used in violation of the provision of this part. Describe: With the newly deployed Grants Management System, invoices are submitted electronically by the vendor or sub-recipient directly to the GMS. Programming Services Officers then review for accuracy against the approved budget and scope of work and either reject the invoice for correction by the vendor or submit to the Assistant Director for approval and submission for payment through the GMS. Fiscal staff review invoices to ensure all expenditures are reasonable and allowable and are charged to the state accounting system general ledger line sequence number that correlates to the CFDA and FAIN of the grant. To ensure tracking of funds adequately, the CCAP financial management team conducts analysis of the data generated for biweekly payment. This information includes status of eligibility, number of records processed, and amounts for union, PAC, copay and net benefit. This information is validated across an average of the last ten batches and provides the Department with additional information to ensure payment integrity. c. Processes and procedures to prepare and submit required state and federal fiscal reporting. Describe: State and federal fiscal reporting is performed by the financial management office utilizing data from the State’s accounting system. Data is analyzed dependent on the reporting requirements and compiled to meet the requirements of the report. The financial management team prepares and submits the reports in the federal reporting system. d. Other. Describe: Financial Management takes additional steps to ensure compliance with uniform grant guidance such as review of single audits and completion for risk assessments. 10.1.3 Effectiveness of fiscal management practices Describe how the Lead Agency knows there are effective fiscal management practices in place for all CCDF expenditures, including: a. How the Lead Agency defines effective fiscal management practices. Describe: The Lead Agency promotes the financial integrity and accountability of state government through sound administrative and accounting controls and procedures, including continued analysis and management of fiscal resources ensuring quality results while adhering to both federal and state rules, regulations and procedures. b. How the Lead Agency measures and tracks results of their fiscal management practices. Describe: The Lead Agency monitors fiscal procedures to ensure control and accountability. Fiscal management practices include having standard operating procedures and internal controls for accounting, financial reporting, budgeting, cash management and other financial related activities. The Lead Agency makes payments to child care providers through an integrated eligibility system (RIBridges). The Office of Child Care and the Office of Financial Management meet each week with the State's technology vendor, Deloitte, to review metrics on recertification progress, enrollment data, and supplemental payroll analysis. These metrics provide the Department with information to adopt procedures to ensure CCAP is operating efficiently and effectively and measure performance to provide context for improvement. The agency provides regular reviews of cost items recorded to CCDF and budget to actual trends. Continuous monitoring, control activities, and communication promote and support program integrity and accountability. c. How the results inform implementation. Describe: The Lead Agency develops and implements coordinated strategies that strengthen fiscal management practices. Monthly grant management meetings, which include communication between fiscal and program staff, are held to establish coordination of activities. Bi-weekly provider payment reviews result in identifying eligibility issues related to specific children which triggers Provider Management review of the case prior to authorizing or denying payment. This also results in coordinating with field operations staff to review the processing of these cases to determine/re-determine eligibility before payments are made. Identifying the root cause for the eligibility issue then informs additional staff training needs, such as the use of circumstances change dates, case merges, wrap up steps. Provider Management also works with providers who need assistance enrolling children timely and/or submitting attendance records timely as part of ensuring accurate and timely payments. Staff training, technical assistance to child care providers and subrecipients is a continuous process. d. Other. Describe: N/A 10.1.4 Identifying risk Describe the processes the Lead Agency uses to identify risk in the CCDF program including: a. Each process used by the Lead Agency to identify risk (including entities responsible for implementing each process). Describe: Prior to contract review/approval and annually thereafter, a Risk Assessment - Pre-Contract Uniform Grant Guidance Compliance is completed for the sub-recipient. Assessment using a numerical grade is completed in areas including SAM.GOV, Audit and Fiscal Statements, Invoicing, Staffing, Legal Risk, Experience with Grant, Data/Reporting, System Changes, Licensing and Safety. In Rhode Island, the Office of Internal Audit (OIA) performs the auditing function for the Executive Branch of State Government. It provides an independent appraisal and evaluation of the effectiveness of financial and operational controls through objective analyses, evaluations, and recommendations on operations, systems, and contracted services of state government. The OIA’s mission is to enhance and protect organizational value by providing risk-based and objective assurance, advice, and insight. In addition, CCDF is audited annually by the Office of the Auditor General as a major program following risk- based criteria established in the federal Uniform Guidance. Our risk assessment forms guide our grants and contracts, and also specifically help with program coordination. We have multiple vendors doing work with multiple projects both in child care as well as other pieces of the agency, and these risk assessments help to identify where that is happening and assign a risk value based on that. In addition, our internal provider monitoring assess risk through monthly audits to ensure providers are tracking how they should be tracking attendance, as well as ensuring families are utilizing their care correctly. Creating and implementing internal processes for risk management has been a key strategy over the last year in order to ensure we are utilizing our funding sources effectively. Program and fiscal departments within the agency work together on systems on checks and balances to assess risk from both a policy and programmatic perspective as well as a financial perspective. b. The frequency of each risk assessment. Describe: Risk Assessment for grants and contracts areis done prior to contract approval and annually thereafter for the duration of the contract. Programming Services Officers conduct bi-weekly contracting meeting with their vendors/sub-recipients to ensure ongoing compliance with contract terms and to address any concerns or changes proactively to minimize risk. The Office of Child Care has bi- monthly quality contract meetings where PSOs and Program Staff review contracting processes, ongoing contracts deliverables and solution any potential issues or risks. Annually, a single state audit is conducted by the Office of the Auditor General in accordance with federal requirements. Our internal risk assessments through provider monitoring are done on a monthly basis to ensure we monitor every provider within a three year period. In addition, more informal risk assessments of CCDF funding between program and fiscal happen on a weekly basis through program finance meetings. c. How the Lead Agency uses risk assessment results to inform program improvement. Describe: The Lead Agency develops and implements coordinated strategies that strengthen risk assessment practices. Results are utilized to drive process design, enhance system controls, and assure alignment with department priorities and strategic goals . For grants and contracts risk assessment, we can either choose to not contract with them or make the determination to monitor them more closely. With provider monitoring risk assessment, we have specialized technical assistance that we are providing for centers or family child care homes that do not hit certain benchmarks and allow for increased future monitoring. Our weekly meetings go through assessments of all types and inform more larger scale decision making. d. How the Lead Agency knows that the risk assessment processes utilized are effective. Describe: There are specific key metrics for both the program risk assessment as well as the financial risk assessment that are used for every contract that is written regardless of funding source. This is important because the risk is being looked at from both lens with different questions on each assessment. The criteria is objectively answered using a scoring system that determines risk. Based on the objective result, increased monitoring of sub-recipients would be done based on DHS procedures. The Department sees the data that supports that the risk assessments, monitoring, and meetings are working because the documented issues are decreasing and being triaged far more proactively. e. Other. Describe: Meetings attended to by program and fiscal staff to ensure potential risks are mitigated and audit recommendations are implemented are held quarterly. 10.1.5 Processes to train about CCDF requirements and program integrity Describe the processes the Lead Agency uses to train staff of the Lead Agency and other agencies engaged in the administration of CCDF, and child care providers about program requirements and integrity. a. Describe how the Lead Agency ensures that all staff who administer the CCDF program (including through MOUs, grants, and contracts) are informed and trained regarding program requirements and integrity. i. Describe the training provided to staff members around CCDF program requirements and program integrity: Contracting staff including Programming Services Officers and Financial Management staff attend required GMS training prior to accessing the Grants Management System and ongoing topic specific training and office hours. There is a library of instructional documents accessible to all GMS users. Vendors/sub-recipients submitting invoices through GMS also attend a required training prior to GMS access and have similar documentation and office hours for ongoing support Eligibility technicians who are responsible for processing customer eligibility have a learning management system course re: recognizing and preventing fraud that, while through a SNAP lens, provides an overview of fraud and program integrity topics relevant to case processing in general. ETs are required to take CCAP specific trainings that cover the importance of accuracy in case processing including both the importance of providing the customer with accurate benefit determinations and preventing improper payments.. Beyond the mandatory trainings, supervisors have the discretion to recommend or require additional trainings to assist staff with specific programs, topics or errors. CSDL tracks and report training completion for operations staff. The policy team, in consultation with CCDF Program leads drafts and delivers policy briefs/transmittals for all staff highlighting policy updates and works closely with program and training teams to ensure materials accurately reflect state and federal policy, rules and regulations. ii. Describe how staff training is evaluated for effectiveness: GMS training is deemed effective when Programming Services Officers, Financial Management Staff and Vendors/Sub-recipients effectively use the system to process, track, invoice and complete contracts with minimal delay or disruption resulting in faster and more accurate processing and efficiencies in reporting. Provider training is deemed effective when, post orientation, Providers accurately enroll children and submit attendance records timely. Trainings for the CCAP benefits operations staff are evaluated based on the Improper Payment error rate as it relates to worker/staff error or omission. Trainings are revised and updated as needed to address repeat errors. CSDL collects post-training survey data and tracks completion by participant for supervisors. iii. Describe how the Lead Agency uses program integrity data (e.g., error rate results, risk assessment data) to inform ongoing staff training needs: Trainings for the operations staff, who determine eligibility and process benefits including CCAP, are evaluated based on the Improper Payment error rate as it relates to worker/staff error or omission. Trainings are revised and updated as needed to address repeat errors. The Center for Staff Development and Learning (CSDL) collects post-training survey data and tracks completion by participant. The error rate results inform in person training, development of additional LMS (Learning Management System) modules for shorter, more targeted topics, implementation of CCAP specific processing labs and scenario-based learning. The error rate informs topics covered in monthly CCAP office hours meetings where operations staff join Program and Policy staff for Q & A sessions. b. Describe how the Lead Agency ensures all providers for children receiving CCDF funds are informed and trained regarding CCDF program requirements and program integrity: i. Describe the training for providers around CCDF program requirements and program integrity: CCAP Providers take a mandatory CCAP Orientation training which covers the background and importance of the CCDF program, the state and federal regulations as relates to enrollment, attendance and payment practices, and the importance of accuracy in both reporting and record keeping. There is a knowledge check question they are required to answer correctly around this topic. In addition, program integrity topics related to accuracy in reporting and record keeping are highlighted in provider all-calls and all-emails. A one-page resource on this was shared with all providers and is part of the resource library on the Lead Agency website. The orientation provides detailed instruction on how to use the CCAP Provider Portal to accurately enroll children and track or change enrollment, how to submit attendance and the schedule to adhere to for timely and accurate payment. It covers rules and expectations around reimbursement rates, authorized hours and billing. The CCAP Provider Agreement, signed by all approved CCAP providers outlines Provider responsibilities related to enrollment and attendance submission, reimbursement/payment rates, authorized hours and includes addenda related to state and federal regulations and requirements. A CCAP Provider Handbook detailing provider responsibility is available to all Providers on the DHS website. All Provider meetings are held quarterly, and topics related to CCDF program requirements are included as reminders or updated as policy changes occur. All Provider emails are used to share any policy changes, to remind providers of CCDF program requirements as needed and to highlight trends or concerns related to program requirements. ii. Describe how provider training is evaluated for effectiveness: The CCAP Provider Orientation has been revised to include interactive quizzes to engage participants in learning and to assess comprehension. A pass rate of 80% is required to obtain a certificate. Incoming questions from Providers are scanned for trends and for points of clarification that are then added to provider communication and flagged for updates in documentation or in the Bridges system. iii. Describe how the Lead Agency uses program integrity data (e.g., error rate results, risk assessment data) to inform ongoing provider training needs: Documentation collected from Providers as part of the Provider Monitoring process is reviewed for completeness and accuracy. Trends in missing documentation or inaccuracies in tracking attendance are clarified in the Orientation training, the Provider Handbook and the CCAP Provider Agreement Terms and Conditions. Technical Assistance is provided for individual providers and added to all-provider emails or calls. TA and follow-up to ensure compliance is required for individual providers with non-compliances. 10.1.6 Evaluate internal control activities Describe how the Lead Agency uses the following to regularly evaluate the effectiveness of Lead Agency internal control activities for all CCDF expenditures. a. Error rate review triennial report results (if applicable). Describe who this information is shared with and how the Lead Agency uses the information to evaluate the effectiveness of its internal controls: Triennial error rate reports are shared with the Center for Staff Development and Learning (CSDL) to include error-related topics in their trainings for operations staff. Results are shared with IT Systems to address potential system changes that would improve accuracy. Results are shared with a cross program team in regular program quality meetings for input and triage where errors and/or proposed changes impact multiple programs. Results are shared with Operations leadership for awareness in supervising processing staff, adding case review labs and monitoring CCAP case processing accuracy. b. Audit results. Describe who this information is shared with and how the Lead Agency uses the information to evaluate the effectiveness of its internal controls: Audit results are shared with the Center for Staff Development and Learning (CSDL) to include error-related topics in their trainings for operations staff. Results are shared with IT Systems to address potential system changes that would improve accuracy and compliance. Results are shared with a cross program team in regular program quality meetings for input and triage where findings and/or proposed changes/solutions could impact multiple programs. Results are shared with Operations leadership for awareness in supervising processing staff, adding case review labs, monitoring CCAP case processing accuracy and input on system enhancements that would help processing accuracy. c. Other. Describe who this information is shared with and how the Lead Agency uses the information to evaluate the effectiveness of its internal controls: N/A 10.1.7 Identified weaknesses in internal controls Has the Lead Agency or other entity identified any weaknesses in its internal controls? a. [ ] No. If no, describe when and how it was most recently determined that there were no weaknesses in the Lead Agency’s internal controls. b. [x] Yes. If yes, what were the indicators? How did you use the information to strengthen your internal controls? Case reviews, error rate findings and fraud findings by Office of Internal Audit (OIA) indicated the need for strengthening internal controls. This information was used to inform targeted training for providers through updated CCAP Orientation training and communication including a revised Provider Handbook. Operations staff trainings have been revised, targeted topics have been added, processing labs have been conducted, monthly office hours have been scheduled ongoing. This information is continually used to identify Bridges systems issues related to eligibility determination, and child enrollment and attendance reporting. This information was used to develop and launch CCAP Provider monitoring beginning February 2024 to ensure Providers adhere to the state’s regulations on maintaining Parent Provider agreements and child attendance/sign-in/out documentation to support Portal attendance submissions that inform provider payments.