County of San Diego Health and Human Services Agency HHSA General Relief Program Guide GRPG System Abuse Sanctions Number Page 901707 1 of 5 Revision Date April 1 2021 A BackgroundThis section provides information on the proper application of a System Abuse Sanction in the General Relief GR Program PurposeThis section has been reformatted to current format This revision also removes references to MonthlyQuarterly Eligibility Reports CW 7sQR 7s B PolicySystem abuse applies to cases in which fraudulent documentation is submitted for the purpose of receiving or increasing the benefit level of GR cash aid C Definition Fraudsystem abuse exists when the customer within their competence knowingly and with intent to defraud commits at least one of the following Makes a false statement or representation to obtain aid a continuance an increase or to avoid a reduction of aid Submits false documents which they knew were false to obtain aid a continuance an increase or to avoid a reduction of aid Fails to disclose a fact which if disclosed could have resulted in denial reduction or discontinuance of aid Receives aid to which they are not entitled D DetectPrevent FraudIn preventing and detecting fraud the Human Services Specialist HSS has the responsibility to take the actions in the table below Step Action 1 Make sure the customer understands all rights and responsibilities including The responsibility to report promptly within five days any fact which could affect the determination of eligibility andor the correct grant amount The penalty for failing to report such facts 2 Assist the customer who appears not to understand their rights and responsibilities and document in the Case Comments concerning the customers understanding of their rights and responsibilities 3 Review the application or case file to Confirm the presence of all mandated verifications Determine if any incomplete inconsistent or conflicting information is present 4 Attempt to clarify with the customer any incomplete inconsistent or conflicting information County of San Diego Health and Human Services Agency HHSA General Relief Program Guide GRPG System Abuse Sanctions Number 901707 Page 2 of 5 E System Abuse Discovery by Fraud Prevention Investigator The table below shows how the case must be handled when a Fraud Prevention Investigator discovers System Abuse Issue Action Policy Fraudulent documents detected and documented in the case record by the Early Fraud DetectionPrevention EFDP Investigator result in a sanction Adverse action is subject to timely and adequate notice requirements and to appeals through the GR Hearing process Referrals See GRPG 901705 Besides the basic information required by the referral system include all known aliases and addresses and the HSS suspicions regarding the fraud in the Comments section Additionally send applicable documentation to the Bureau of Public Assistance Investigations BPAI including photocopies of all questionable documents Questionable documents may include ID cards drivers license rent receipts birth certificates medical verification noncitizen registration cards etc Examples of questionable proof of housing costs which should be referred to Early Fraud DetectionPrevention EFDP include Rent receipts or affidavits of living situation with unresolved conflicting or incomplete information following discussion with the customer andor third party Rent receipts the HSS has reason to suspect were written by the customer Information given by the customer which conflicts with the assessors files Sanction Periods The sanction periods for system abuse detected by the EFDP Investigator or BPAI Full Field Investigator are shown below Instance Sanction Period First 30 days from the date of denial or discontinuance Second 90 days from the date of denial or discontinuance Third or 180 days from the date of denial or discontinuance this includes subsequent situations where the HSS had previously applied a 30andor 90day sanction F System Abuse Discovery by Human Services Specialist HSS The table below shows how the case must be handled when the HSS discovers System Abuse Issue Policy Action Fraudulent documents detected by the HSS result in a sanction These sanctions apply to applicants as well as recipients and are subject to the GR hearing process Take action to sanction the case with timely and adequate notice when CalFresh MediCal or CalWORKs case documentation including County of San Diego Health and Human Services Agency HHSA General Relief Program Guide GRPG Number Page System Abuse Sanctions 901707 3 of 5 IEVSPVSMEDS records is discrepant with GR forms such as the Statement of Facts Lien or sworn statements on file and this information was known to the customer at the time documents were submitted Falsified medical evidence is provided by the customer as proof of inability to comply with employable program requirements or good cause for noncompliance with a requirement Thoroughly review case circumstances prior to taking adverse action This allows HSSs to identify customers who have genuinely made a mistake Document the reason for not sanctioning the case If the HSS is unable to verify fraudulent documents refer to the EFDP Investigator for followup Second and subsequent detection must be referred to the EFDP Investigator Case Case documentation must demonstrate that a thorough investigation of the Documentation facts was made prior to taking adverse action or to document the reason for not taking adverse case action All system abuse documentation will be filed under the Fraud tab in the case file The table below shows some examples Ex Situation 1 IEVSPVSMEDS forms showing income property or work history discrepancies with the GR Statement of Facts Lien or other sworn statements on file and a Case Comment entry explaining the discrepancy andor resolution of the discrepancy 2 CalFresh CalWORKs or MediCal Full Field Quality Control letter reporting information which differs along with a Case Comment explaining the discrepancy andor resolution of it 3 A Case Comment stating that medical evidence provided by the customer was determined to be fraudulent The Case Comment will include Date the medical statement was provided by the customer Source of information leading to determination of fraud such as AMA licensing information thirdparty contact etc Types and dates of thirdparty contacts if any First and last name and the title or position of the contact person direct quotes from third party contacts will be noted on form 1114 HHSA Sanction Periods The sanction periods for system abuse detected by the HSS are shown below Third and subsequent instances of system abuse will be referred to the EFDP Investigator for necessary action Instance First Second and subsequent Sanction Period 30 days from the date of denial or discontinuance 90 days from the date of denial or discontinuance County of San Diego Health and Human Services Agency HHSA General Relief Program Guide GRPG Number Page System Abuse Sanctions 901707 4 of 5 Note Sanctions for system abuse and willful failure to comply with employable program requirements will be applied concurrently Example Employable recipient Initial aid paid Fraudulent medical verification provided System abuse sanction is 30 days Employable sanction is three months unless shortened by MAPC option G Welfare Fraud Convictions The table below shows how the case must be handled after a Welfare Fraud Conviction Issue Action Policy Cases in which recipients have been convicted by a court for either a misdemeanor or felony welfare fraud related to the GR cases shall be subject to a sanction Once the case is prosecuted the HSS will be notified by the disposition Documentation A copy of the court order or sentence order is documentation of a welfare fraud conviction BPAI will forward a copy of the form to the appropriate FRC Manager with an identification of the last known worker The FRC administration will forward documentation to the last worker of record Image the court order or sentence order in the case file If the case Then Is in intake and has Deny the application Issue an adequate notice not been granted including the period of sanction Has been granted Discontinue the case Issue a timely and adequate notice including the period of sanction Is closed Order the case write a Case Comment on the conviction and the appropriate period of sanction Sanction Periods The table below shows the sanction periods Instance Sanction Period First Six months from the date of conviction or date of release jail or prison whichever is later Second 12 months from the date of conviction or date of release whichever is later Third Permanently Note Convictions occurring prior to June 10 1991 will not be considered in applying sanctions for welfare fraud Procedure Follow the actions in the policies above to evaluate System Abuse and Convicted Fraud sanctions County of San Diego Health and Human Services Agency HHSA General Relief Program Guide GRPG System Abuse Sanctions Number Page 901707 5 of 5 Other Program ImpactsNone References County Policy Sunset Date This policy will be reviewed for continuance by March 31 2024 Approval for Release Rick Wanne Director Eligibility Operations