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DHS On-Site Review and Monitoring Financial Compliance Review Process

Financial Compliance On-site Reviews of DHS Service Providers are conducted based on the reasons noted below:

  • State/federal mandates
  • Recommendations by DHS senior management
  • Recommendations by DHS Bureau of Financial Management
  • Recommendations by DHS program staff
  • Contract amount under $500,000 (not required to submit a certified audit)
  • Findings or management comments included in the certified audit received by DHS
  • DHS cyclical review schedule
  • Results of risk assessment
  • Director's Action Line (DAL) concerns

The following items are reviewed during a financial compliance on-site review of a DHS service provider:

  • Internal accounting controls
  • Fee-for-service program controls
  • Fee-for-service billings
  • Invoice claims
  • Expenditures
  • Compliance with contract terms,
  • Compliance with funding regulations, (e.g., Pa. State Bureau of
    Drug and Alcohol Programs (DDAP), Labor and Industry, etc.)
  • Personnel Action Plan for MH/D&A/MR service providers
  • Current year agreements are monitored
  • Board of directors composition and meeting minutes

NOTE: DHS deputy directors and monitors are notified before fiscal monitoring field work begins and are asked if they have any fiscal concerns or issues with the service provider.

DHS service providers undergo periodic reviews at intervals depending on various criteria. The following is the fiscal monitoring work schedule:  

  • Pa. State Department of Drug and Alcohol Programs (DDAP)
    All drug and alcohol providers are monitored annually, beginning in November and finishing by March 31. Follow-up monitoring is required for those providers that have findings, or areas of concern. Follow-up monitoring begins in July and is completed by September 30.
  • Room and board/Client funds
    Office of Intellectual Disability - Residential Service Providers. Client accounts are monitored every two years.
  • All other service providers (including providers under Personnel Action Plan (PAP)
    May be conducted on a cyclical review schedule or based on
    recommendations from DHS management and program office staff.

DHS fiscal monitoring procedures are conducted as follows:  

  • Priority Monitoring
    The DHS Office of Administrative and Information Management Services will typically focus attention on providers that pose a greater financial risk to DHS. The factors DHS will usually employ are:
    •  1) is the provider required to submit a certified audit
    •  2) the amount of funding
    •  3) results of prior reviews; and
    • 4) if there are findings and recommendations included in prior audits or reviews. At a minimum, high-risk providers are monitored annually. Low-risk providers are monitored once every three years.
  • Monitoring
    Financial compliance monitoring is conducted using a fiscal monitoring work program. All on-site reviews result in a report being submitted to the service provider, county manager, DHS director and DHS deputy director.
  • Corrective Action Plan
    If the on-site review identifies a "finding" or area of concern, the service provider is required to submit a Corrective Action Plan (CAP) within two weeks of the date of the report. The CAP must address how "control weaknesses" or compliance findings will be resolved and a timeline for implementing the CAP.
  • Determination Letter
    Once a CAP is submitted, the fiscal monitor will review it to determine if it appropriately addresses the findings identified in the report. If the CAP does not adequately address the findings, the fiscal monitor will request additional information. An acceptance letter is sent to the service provider once the CAP is approved.
  • Technical Assistance
    A technical assistance meeting is held annually for all service providers. This meeting addresses contracting, insurance, invoicing, new regulations, programmatic issues and contract compliance information. Additionally, technical assistance is provided on-site at any time for those service providers that request it.

The Personnel Action Plan (PAP)  

All service providers receiving mental health, drug and alcohol and intellectual disability funding based on cost reimbursement through DHS are required to submit a Personnel Action Plan (PAP) each contract year. A review of the PAP is included in the procedures performed during the on-site review.

The PAP is reviewed to ensure conformity with governing regulations.

The PAP includes agency policies concerning:

  • salaries,
  • fringe benefit rates,
  • COLA's,
  • appointments,
  • bonuses,
  • merit salary increases,
  • promotions,
  • reclassifications,
  • position abolishment,
  • demotions,
  • EEO/Affirmative Action and
  • authorizations to create new positions.

The PAP also includes a current organizational chart and evidence of board of directors' approval.

Allegheny County Controller Single Audit 

The County Controller's single audit of DHS is conducted annually, February through April, by the County Controller's office audit staff. The audit includes the following procedures.

  • Reviews and evaluates DHS internal controls
  • Reviews a sample of DHS contracts
  • Reviews a sample of certified audits of DHS service providers
  • Reviews a sample of invoices
  • Reviews a sample of DHS fiscal compliance review files