EIN: 996001089
UEI: F5SRLH4ZQGM4
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 30, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 30, 2026 (33 days from today).
What is a management decision? →Condition During our audit, we selected a non-statistical sample of 60 participant files which approximated $42,000 in monthly payments, out of a population of approximately 174,800 participant files which approximated $693 million in total annual benefit payments, for testing and noted exceptions in 10 case files as follows: • One case file where manually entered income and deduction amounts did not agree with the documentation retained in the participant’s case file. • Four case files where manually entered deduction amounts did not agree with the documentation retained in the participant’s case files. • One case file where manually entered income information did not agree with the documentation retained in the participant’s case file. • Two case files where the documentation did not show proper eligibility determination. • Two case files where the documentation did not show proper eligibility determination and manually entered income information did not agree with the documentation retained in the participant’s case file. A similar finding was reported in the prior year as Finding No. 2024-005. Criteria Pursuant to 7 CFR 272.10(b)(1)(i), the SNAP system should be efficiently automated to determine eligibility and calculate benefits or validate the eligibility worker’s calculations by processing and storing all case file information necessary for the eligibility determination and benefit computation (including but not limited to all household members’ names, addresses, dates of birth, social security numbers, individual household members’ earned and unearned income by source, deductions, resources, and household size). Effect Participants received more or did not receive the full amount of benefits they were eligible for, resulting in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant’s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non-statistical sample of 60 participant files which approximated $42,000 in monthly payments, out of a population of approximately 174,800 participant files which approximated $693 million in total annual benefit payments, for testing and noted exceptions in 10 case files as follows: • One case file where manually entered income and deduction amounts did not agree with the documentation retained in the participant’s case file. • Four case files where manually entered deduction amounts did not agree with the documentation retained in the participant’s case files. • One case file where manually entered income information did not agree with the documentation retained in the participant’s case file. • Two case files where the documentation did not show proper eligibility determination. • Two case files where the documentation did not show proper eligibility determination and manually entered income information did not agree with the documentation retained in the participant’s case file. A similar finding was reported in the prior year as Finding No. 2024-005. Criteria Pursuant to 7 CFR 272.10(b)(1)(i), the SNAP system should be efficiently automated to determine eligibility and calculate benefits or validate the eligibility worker’s calculations by processing and storing all case file information necessary for the eligibility determination and benefit computation (including but not limited to all household members’ names, addresses, dates of birth, social security numbers, individual household members’ earned and unearned income by source, deductions, resources, and household size). Effect Participants received more or did not receive the full amount of benefits they were eligible for, resulting in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant’s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: We have implemented a training plan and discussed efficiencies by operations staff to improve accuracy and timeliness. This has been a priority since January 2025. We will be transitioning to a new eligibility system starting October 2026 which should assist in improving the accuracy. Expected Completion Date: Ongoing Responding Official(s): Ginet Hayes, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator
2024-005
Condition During our audit, we selected a non-statistical sample of 60 daily reconciliations for testing and noted eight instances where variances were not investigated and there was no evidence that a review of the daily reconciliation was performed. The Department’s daily reconciliations identified variances totaling approximately $4.9 million. A similar finding was reported in the prior year as Finding No. 2024-004. Criteria Pursuant to 7 CFR 274.4, the Department is required to perform daily reconciliations of all SNAP transactions between the State’s Benefit Account, the US Treasury Department, and all the EBT contractors. Effect Failure to resolve the reconciling items resulted in non-compliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require a supervisor sign-off documenting their review resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliation is reviewed in a timely manner.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non-statistical sample of 60 daily reconciliations for testing and noted eight instances where variances were not investigated and there was no evidence that a review of the daily reconciliation was performed. The Department’s daily reconciliations identified variances totaling approximately $4.9 million. A similar finding was reported in the prior year as Finding No. 2024-004. Criteria Pursuant to 7 CFR 274.4, the Department is required to perform daily reconciliations of all SNAP transactions between the State’s Benefit Account, the US Treasury Department, and all the EBT contractors. Effect Failure to resolve the reconciling items resulted in non-compliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require a supervisor sign-off documenting their review resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliation is reviewed in a timely manner.
Views of Responding Officials: The Department agrees with the finding, will implement corrective action, and will work with the appropriate parties to address this issue. Corrective Action Taken or Planned: The EBT accounts will be reconciled daily, and once completed, will be reviewed and signed off by the accounting supervisor. If discrepancies are found, they will be checked against the detailed Fidelity National Information Services (FIS) and the Office of Enterprise Technology (OET) reports. Expected Completion Date: June 2026 Responding Official(s): Joey Wong, Fiscal Management Office Accounting Supervisor
2024-004
Condition We selected a non-statistical sample of three subrecipients and noted that in each case, the Department did not perform required during-the-award monitoring of its subrecipients. In addition, the Department did not verify that that subrecipients were audited if required by 2 CFR Part 200, Subpart F. Criteria Pursuant to 2 CFR 200.332(d), pass-through entities must monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Pursuant to 2 CFR 200.332(f), pass through entities must verify that subrecipients expected to be audited as required by 2 CFR Part 200, Subpart F, met this requirement. Effect Failure to monitor subrecipient activities or verify that subrecipients have completed their required Single Audits increases the risk that noncompliance at the subrecipient level goes undetected. Cause and View of Responsible Officials The issue occurred during a period of staff transition, during which roles were assumed without the benefit of documented procedures, formal training, or established prior practices. Recommendation We recommend that the Department establish formal written policies and procedures to ensure that the required during-the-award monitoring is performed and the required subrecipient Single Audit reports are obtained and reviewed, including appropriate follow up on any relevant audit findings.
Show full finding ▾Hide full finding ▴Condition We selected a non-statistical sample of three subrecipients and noted that in each case, the Department did not perform required during-the-award monitoring of its subrecipients. In addition, the Department did not verify that that subrecipients were audited if required by 2 CFR Part 200, Subpart F. Criteria Pursuant to 2 CFR 200.332(d), pass-through entities must monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Pursuant to 2 CFR 200.332(f), pass through entities must verify that subrecipients expected to be audited as required by 2 CFR Part 200, Subpart F, met this requirement. Effect Failure to monitor subrecipient activities or verify that subrecipients have completed their required Single Audits increases the risk that noncompliance at the subrecipient level goes undetected. Cause and View of Responsible Officials The issue occurred during a period of staff transition, during which roles were assumed without the benefit of documented procedures, formal training, or established prior practices. Recommendation We recommend that the Department establish formal written policies and procedures to ensure that the required during-the-award monitoring is performed and the required subrecipient Single Audit reports are obtained and reviewed, including appropriate follow up on any relevant audit findings.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Due to staffing shortages within the Supplemental Nutrition and Assistance Program office (SNAPO), this has and will continue to be an area of focus for improvement and will be an action item for the fiscal year 2026. Corrective Action Taken or Planned: SNAPO intends to conduct regular fiscal reviews of all contracts beginning March 2026. Completion Date: August 31, 2026 Responding Official(s): Ginet Hayes, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator
Condition During our audit, we selected a non-statistical sample of 60 individuals for testing out of a population of approximately 434,000 enrollments. The enrollments selected for testing represented approximately $286,000 of payments out of a total payment population of $2.1 billion. We identified one enrollment whose benefits were not timely terminated after failing to provide verification to support revalidation. A similar finding was reported in the prior year as Finding No. 2024-014. Criteria Title 42 CFR Part 435.912 requires the timely determination of eligibility of individuals who apply for Medicaid benefits within 1) 90 days for applicants who apply for Medicaid on the basis of disability (MAGI-excepted), and 2) 45 days for all other applicants (MAGI). In addition, Title 42 CFR Part 435.916 requires annual re-verifications of participant eligibility. Effect Failure to follow the established policies and procedures in place over the Medicaid eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department implement training and standard operating procedures to ensure eligibility determinations are completed in a timely manner.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non-statistical sample of 60 individuals for testing out of a population of approximately 434,000 enrollments. The enrollments selected for testing represented approximately $286,000 of payments out of a total payment population of $2.1 billion. We identified one enrollment whose benefits were not timely terminated after failing to provide verification to support revalidation. A similar finding was reported in the prior year as Finding No. 2024-014. Criteria Title 42 CFR Part 435.912 requires the timely determination of eligibility of individuals who apply for Medicaid benefits within 1) 90 days for applicants who apply for Medicaid on the basis of disability (MAGI-excepted), and 2) 45 days for all other applicants (MAGI). In addition, Title 42 CFR Part 435.916 requires annual re-verifications of participant eligibility. Effect Failure to follow the established policies and procedures in place over the Medicaid eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department implement training and standard operating procedures to ensure eligibility determinations are completed in a timely manner.
Views of Responsible Officials: The Department agrees with the finding and will implement corrective action. Upon review of the case, it was determined that the caseworker did not trigger a renewal in the Kauhale On-Line Eligibility Assistance System (KOLEA) when the member called to renew by phone. The member reported income to the worker and was advised to provide verification; however, the worker did not trigger a renewal in the system, which prevented an N01 notice from being sent to request verification. The case remained open because the worker did not trigger a Verification Line Item (VLI) for income for the member in KOLEA. The case was later processed through a system data fix, and the member was ex parte renewed and given a new certification period. Corrective Action Taken or Planned: The Eligibility Renewals: Processing DHS 1100B-2 Form Job Aid will be updated to provide instructions for processing non-ex parte renewals completed by phone. Steps on how to properly trigger a renewal in KOLEA will be added to the existing guidance, including detailed screenshots. These updates will enable workers to process renewals consistently, whether they are submitted via form or conducted by phone. The additions to the Job Aid will ensure that a renewal is triggered correctly in the system and that request for verification N01 notices are triggered appropriately when non-ex parte renewals are completed by phone. Expected Completion Date: March 18, 2026 Responding Official(s): Lori-Lei Aponte, Med-QUEST Eligibility and Enrollment Administrator
2024-014
Condition We selected a non-statistical sample of 60 case files which approximates $29,160 in monthly benefit payments, out of a population of approximately 1,400 case files which approximate $22.2 million in total annual benefit payments, for testing and noted exceptions in 13 case files as follows: • Ten case files where the modified or initial adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • One case file where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. • Five case files where the “difficulty of care” determination was missing and therefore did not have any support for the assistance amount paid. • Two case files where the documentation regarding the continuation of the monthly subsidy payments after the child’s 18th birthday was missing. A similar finding was reported in the prior year as Finding No. 2024-006. Criteria Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 673(c)(1)(B), a difficulty of care determination is required to be completed in order to verify that the child qualifies as having special needs. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non-statistical sample of 60 case files which approximates $29,160 in monthly benefit payments, out of a population of approximately 1,400 case files which approximate $22.2 million in total annual benefit payments, for testing and noted exceptions in 13 case files as follows: • Ten case files where the modified or initial adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • One case file where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. • Five case files where the “difficulty of care” determination was missing and therefore did not have any support for the assistance amount paid. • Two case files where the documentation regarding the continuation of the monthly subsidy payments after the child’s 18th birthday was missing. A similar finding was reported in the prior year as Finding No. 2024-006. Criteria Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 673(c)(1)(B), a difficulty of care determination is required to be completed in order to verify that the child qualifies as having special needs. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Moving forward, it would be beneficial for CWS to hold entrance and exit interviews. The entrance interview would be sharing the tool with the auditors, and the exit interview would be explaining major audit findings and discussion to the final report. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Reviewing their work to ensure diligent compliance with policies and procedures. B. Supervisor coaching, support and review of records/documents for completeness. C. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staff is securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated and ensuring filed in eligibility record. C. Locate or reprint and file missing “Certificate of Approvals.” D. Locate missing clearances in records not provided for review or re-run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. E. For young person(s) in Imua Kakou (IK) who turned 18 while in care, i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document (reason for) continuation of monthly subsidy payments after youth turned 18. 3. CWS has identified the Eligibility Unit (FPPEU) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit by following checklists and securing missing documentation, updating inaccurate information and verifying that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Strategies will be developed with Supervisors to support coaching/supervision to ensure appropriate documentation is reviewed to catch and correct errors. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (SSA) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1-5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Completion Date: May 31, 2026 Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator; Lavina Forvilly, Social Services Division Assistant Program Administrator; and Corey Pablo, Social Services Division Management Information Compliance Unit Supervisor
2024-006
Condition We selected a non-statistical sample of 60 case files which approximated $45,440 in monthly benefit payments, out of a population of 361 case files which approximated $4.9 million in total annual benefit payments, for testing and noted exceptions in 13 case files as follows: • Eleven case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • Two case file where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing in the case files. A similar finding was reported in the prior year as Finding No. 2024-007. Criteria Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The "Guardianship/Permanency Assistance Agreement” (“Agreement”) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department and includes the total amount of assistance payments. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 671(a)(20)(c), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount, represents an instance of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non-statistical sample of 60 case files which approximated $45,440 in monthly benefit payments, out of a population of 361 case files which approximated $4.9 million in total annual benefit payments, for testing and noted exceptions in 13 case files as follows: • Eleven case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • Two case file where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing in the case files. A similar finding was reported in the prior year as Finding No. 2024-007. Criteria Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The "Guardianship/Permanency Assistance Agreement” (“Agreement”) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department and includes the total amount of assistance payments. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 671(a)(20)(c), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount, represents an instance of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Moving forward, it would be beneficial for CWS to hold entrance and exit interviews. The entrance interview would be sharing the tool with the auditors, and the exit interview would be explaining major audit findings and discussion to the final report. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Reviewing their work to ensure diligent compliance with policies and procedures. B. Supervisor coaching, support and review of records/documents for completeness. C. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staff is securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Locate or reprint and file missing “Certificate of Approvals.” C. Locate missing clearances in records not provided for review or re-run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. 3. CWS has identified the Eligibility Unit (FPPEU) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit by following checklists and securing missing documentation, updating inaccurate information and verifying that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Strategies will be developed with Supervisors to support coaching/supervision to ensure appropriate documentation is reviewed to catch and correct errors. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (SSA) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1-5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Completion Date: May 31, 2026 Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator; Lavina Forvilly, Social Services Division Assistant Program Administrator; and Corey Pablo, Social Services Division Management Information Compliance Unit Supervisor
2024-007
Condition We selected a non-statistical sample of 60 case files which approximate $43,500 in monthly benefit payments, out of a population of 381 case files which approximated $3.33 million in total annual benefit payments, for testing and noted exceptions in three case files as follows: • Two files where the state, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing or not completed prior to becoming licensed and receiving benefit payments. • One case file where the “difficulty of care” determination was missing and therefore did not support the assistance amount paid. A similar finding was reported in the prior year as Finding No. 2024-008. Criteria Pursuant to 42 USC 675(4)(A), the foster care maintenance payments should cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, and a child’s personal incidentals. Pursuant to 42 USC 671(a)(20)(A), any prospective foster parent must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases, before the foster parent may be finally approved for placement of a child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represent instances of noncompliance with the requirements above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non-statistical sample of 60 case files which approximate $43,500 in monthly benefit payments, out of a population of 381 case files which approximated $3.33 million in total annual benefit payments, for testing and noted exceptions in three case files as follows: • Two files where the state, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing or not completed prior to becoming licensed and receiving benefit payments. • One case file where the “difficulty of care” determination was missing and therefore did not support the assistance amount paid. A similar finding was reported in the prior year as Finding No. 2024-008. Criteria Pursuant to 42 USC 675(4)(A), the foster care maintenance payments should cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, and a child’s personal incidentals. Pursuant to 42 USC 671(a)(20)(A), any prospective foster parent must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases, before the foster parent may be finally approved for placement of a child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represent instances of noncompliance with the requirements above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Moving forward, it would be beneficial for CWS to hold entrance and exit interviews. The entrance interview would be sharing the tool with the auditors, and the exit interview would be explaining major audit findings and discussion to the final report. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Reviewing their work to ensure diligent compliance with policies and procedures. B. Supervisor coaching, support and review of records/documents for completeness. C. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated and ensuring filed in eligibility record. B. Locate or reprint and file missing “Certificate of Approvals.” C. Locate missing clearances in records not provided for review or re-run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. 3. CWS has identified the Eligibility Unit (FPPEU) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staff (Licensing, CWS and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit by following checklists and securing missing documentation, updating inaccurate information and verifying that all necessary documentation is present. i. Staff may be given individual training or coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Strategies will be developed with Supervisors to support coaching/supervision to ensure appropriate documentation is reviewed to catch and correct errors. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (SSA) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1-5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Completion Date: May 31, 2026 Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator; Lavina Forvilly, Social Services Division Assistant Program Administrator; and Corey Pablo, Social Services Division Management Information Compliance Unit Supervisor
2024-008
Condition We selected a non-statistical sample of three subrecipients and noted that the Department did not perform site-visits for two subrecipients as required by the Department’s policy and procedures. Criteria Pursuant to 2 CFR 200.332(d), pass-through entities must monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Effect Failure to monitor subrecipients increases the risk that noncompliance at the subrecipient level goes undetected. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non-statistical sample of three subrecipients and noted that the Department did not perform site-visits for two subrecipients as required by the Department’s policy and procedures. Criteria Pursuant to 2 CFR 200.332(d), pass-through entities must monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Effect Failure to monitor subrecipients increases the risk that noncompliance at the subrecipient level goes undetected. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Child Welfare Services will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Corrective Action Taken or Planned: 1. Social Services Division (SSD) will contact providers stated above in writing to request the Single Audit Summary Report. Once received, SSD will submit the reports to Accuity, LLC. 2. SSD staff responsible for collecting the Single Audit Summary report will complete refresher training related to the Federal Audit Reporting requirements. 3. POS will send a reminder to providers to submit a Single Audit Report in compliance with Special Conditions of their contract once expending over $1,000,000 in the Fiscal Year in compliance with the Federal Audit Requirements. Completion Date: May 31, 2026 Responding Official(s): Stacie Pascual, Social Services Division Child Welfare Services Program Development Administrator; Elliot Plourde, Social Services Division Assistant Program Administrator; Joshua Selman, Social Services Division Purchase of Services (POS) Program Specialist; Elladine Olevao, Acting Social Services Division Administrator; Lavina Forvilly, Social Services Division Assistant Program Administrator; and Corey Pablo, Social Services Division Management Information Compliance Unit Supervisor
Condition We selected a non-statistical sample of 60 participant files, representing approximately $43,600 of monthly benefit payments, out of a population of approximately 2,500 cases, representing approximately $41.5 million of benefit payments, for testing and noted exceptions in four case files as follows: • Four case files where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. A similar finding was reported in the prior year as Finding No. 2024-010. Criteria The State of Hawaii TANF State Plan states that a review of all eligibility requirements is required every 12 months for all TANF households. The State Plan also states that for the Department to make a decision regarding an applicant’s eligibility, an interview must be conducted with the applicant no later than forty-five (45) days after the application is received. Effect Failure to follow the established procedures in place over the eligibility determination process resulted in non-compliance with the requirement and questioned costs. Cause and View of Responsible Officials The Department has a history of backlogged cases, which does not allow them to work on current issues when they arise. Recommendation We recommend that the Department work with Administration for Children and Families to determine what remediation actions, if any, are required.
Show full finding ▾Hide full finding ▴Condition We selected a non-statistical sample of 60 participant files, representing approximately $43,600 of monthly benefit payments, out of a population of approximately 2,500 cases, representing approximately $41.5 million of benefit payments, for testing and noted exceptions in four case files as follows: • Four case files where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. A similar finding was reported in the prior year as Finding No. 2024-010. Criteria The State of Hawaii TANF State Plan states that a review of all eligibility requirements is required every 12 months for all TANF households. The State Plan also states that for the Department to make a decision regarding an applicant’s eligibility, an interview must be conducted with the applicant no later than forty-five (45) days after the application is received. Effect Failure to follow the established procedures in place over the eligibility determination process resulted in non-compliance with the requirement and questioned costs. Cause and View of Responsible Officials The Department has a history of backlogged cases, which does not allow them to work on current issues when they arise. Recommendation We recommend that the Department work with Administration for Children and Families to determine what remediation actions, if any, are required.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The program office will continue to issue reminders to the eligibility staff, during the monthly Statewide Branch Joint Section Meetings, which are attended by the Branch Administrators, Section Administrators who have direct oversight of the Processing Centers, and Processing Center Supervisors. Reminders will include specific topics and common errors found during informal case reviews such as, but not limited to, Temporary Assistance for Needy Families (TANF) application processing, interpretation and application of TANF policies, and eligibility determinations. The program office issued TANF Program Operational Procedure (POP) 01-002, Upfront Universal Engagement (UFUE) for TANF and TAONF Applicants, in 2022. TANF POP 01-002 provides eligibility staff guidance on processing applications for families who are required to meet the upfront requirements prior to eligibility determination. In conjunction with TANF POP 01-002, First-To-Work (FTW) POPs 02-101 and 02-102, issued in 2022, provide FTW staff guidance on the UFUE requirements for TANF applicants. A reminder will be issued to the eligibility and FTW staff on TANF POP 01-002 and FTW POPs 02-101 and 02-102. Delays to applicants’ ability to fulfill the UFUE requirements as a condition of eligibility may impact applications being processed and eligibility determinations being made timely. Completion Date: Ongoing Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2024-010
Condition We selected a non statistical sample of three subawards for testing and noted two subawards where the reporting required by the Federal Funding Accountability and Transparency Act (“FFATA”) was not completed. Criteria Under FFATA, the Department is required to report first-tier subawards of $30,000 or more by the end of the month following the month in which the obligation was made. Effect Failure to file required reports reduces transparency on the use of program funds and represents noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non statistical sample of three subawards for testing and noted two subawards where the reporting required by the Federal Funding Accountability and Transparency Act (“FFATA”) was not completed. Criteria Under FFATA, the Department is required to report first-tier subawards of $30,000 or more by the end of the month following the month in which the obligation was made. Effect Failure to file required reports reduces transparency on the use of program funds and represents noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responsible Officials: The Department agrees with the finding and will implement corrective action. The program personnel are familiar with grant reporting requirements. For the federal fiscal year 2025, there were 62 federal Temporary Assistance for Needy Families(TANF)-funded contracts that were required to be reported in accordance with the Federal Funding Accountability and Transparency Act (FFATA), but two contracts were inadvertently overlooked and were not entered into SAM.gov (replaced now obsolete FFATA Sub-award Federal Reporting System or FSRS). Corrective Action Taken or Planned: The program office implemented internal procedures which conform to the FFATA reporting requirements. 1. A “TANF FFATA Report Template” was created by the program office. 2. Program specialists (contract monitors) are required to complete the “TANF FFATA Report Template” and submit to the program administrator within seven (7) days after a federal-funded contract is executed. 3. Program administrator enters the contract information into SAM.gov following the receipt of the completed “TANF FFATA Report Templates” from the program specialists. Program administrator will take additional steps to ensure the “TANF FFATA Report Template” is received for all federally funded TANF contracts and create a checklist to ensure all contracts have been entered into the SAM.gov, ensuring to avoid any inadvertently missed contracts. Expected Completion Date: July 1, 2026 Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
Condition We selected a non-statistical sample of 60 case files for testing and noted one instance where the Department’s records did not support the use of the income information obtained through the Income Eligibility and Verification System (“IEVS”) to evaluate or re-evaluate the benefit calculation. A similar finding was reported in the prior year as Finding No. 2024-012. Criteria Pursuant to 45 CFR 205.55, the Department is required to request through the IEVS system, wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Effect Failure to properly use IEVS information to evaluate benefit amounts resulted in potential over payment of benefits. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non-statistical sample of 60 case files for testing and noted one instance where the Department’s records did not support the use of the income information obtained through the Income Eligibility and Verification System (“IEVS”) to evaluate or re-evaluate the benefit calculation. A similar finding was reported in the prior year as Finding No. 2024-012. Criteria Pursuant to 45 CFR 205.55, the Department is required to request through the IEVS system, wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Effect Failure to properly use IEVS information to evaluate benefit amounts resulted in potential over payment of benefits. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. No comments regarding the case in which income was not considered when eligibility determination was made and benefits calculated. According to documents found in the electronic case file, the household reported on their annual recertification application that a household member is employed and copies of pay statements were provided. Corrective Action Taken or Planned: Eligibility staff will be reminded to: 1. Thoroughly review the DHS 1240, Application for Financial and SNAP Assistance, for all initial and annual recertifications; 2. Conduct an IEVS check and document on form DHS 1006, Eligibility Determination; 3. Complete the DHS 1006 based on information provided on the DHS 1240 and with the information obtained during the applicant/recipient’s eligibility interview; and 4. Follow up on any missing information or any discrepancies with information provided by the applicant/recipient and information obtained through third-party queries. Expected Completion Date: October 1, 2026 Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2024-012
Condition We selected a non-statistical sample of five grant awards and noted one instance where only 2.7% of program expenditures were made for improving the quality of care for infants and toddlers, which was below the required threshold of 3.0%. The Department’s expenditures for improving the quality of care for infants and toddlers were approximately $197,000 below the required amount. Criteria Pursuant to 45 CFR § 98.50(b)(2), no less than three percent of funds expended shall be used to carry out activities related to the quality of care for infants and toddlers. Effect Failure to spend the required earmarking requirement represents an instance of noncompliance with the requirements of 45 CFR § 98.50(b)(2). Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non-statistical sample of five grant awards and noted one instance where only 2.7% of program expenditures were made for improving the quality of care for infants and toddlers, which was below the required threshold of 3.0%. The Department’s expenditures for improving the quality of care for infants and toddlers were approximately $197,000 below the required amount. Criteria Pursuant to 45 CFR § 98.50(b)(2), no less than three percent of funds expended shall be used to carry out activities related to the quality of care for infants and toddlers. Effect Failure to spend the required earmarking requirement represents an instance of noncompliance with the requirements of 45 CFR § 98.50(b)(2). Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Child Care Regulation Program Office reviewed the program expenditures that were categorized as Infant and Toddler quality activities and found several expenditures that were not being categorized as Infant and Toddler quality activities for Grant Year 2022. Instead, the expenditure was categorized as Quality expenditures. We are currently working with the Fiscal Management Office to reconcile the difference and will update the ACF 696-report. Expected Completion Date: March 11, 2026. Responding Official(s): Dayna Luka, Benefit, Employment, and Support Services Division Child Care Regulation Program Administrator
FAC accepted this audit on March 28, 2025 — management decision was due September 28, 2025.
Finding No. 2024 003: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ - Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561 and COVID 19 – 10.561 – Supplemental Nutrition and Assistance (“SNAP”) Cluster Award Number and Award Year: 7HI400HI4 2022 – 2024 7HI430HI4 2022 – 2024 7HI430HI5 2021 – 2024 7HIHI7F1003 2022 – 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of four processing centers out of the Department’s 20 processing centers and noted that supervisor reviews over DHS Form 1494, Form 1495, and/or DHS Form 1050 were not properly performed at two processing centers. A similar finding was reported in the prior year as Finding No. 2023 003. Criteria Pursuant to 7 CFR 274.8(b)(3), the Department is required to ensure there are storage and control measures to control blank unissued electronic benefit transfer (“EBT”) cards. To address this requirement, the Department has adopted a policy that requires (1) monthly or quarterly review of the Department Form 1494, Bulk Inventory Control Log; (2) daily or weekly review of the Department Form 1495, Hawaii EBT Card Daily Control Log; and (3) monthly review of the Department Form 1050, EBT Card Destruction Control Log. Effect Documentation of supervisor approval of the review over the Department Form 1494, Form 1495, and/or DHS Form 1050 was not properly performed at two processing centers, increasing the risk of non compliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the personnel changes in the past years resulted in inconsistent application and documentation of supervisor reviews. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department periodically reviews the policies and procedures with the supervisors.
Show full finding ▾Hide full finding ▴Finding No. 2024 003: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ - Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561 and COVID 19 – 10.561 – Supplemental Nutrition and Assistance (“SNAP”) Cluster Award Number and Award Year: 7HI400HI4 2022 – 2024 7HI430HI4 2022 – 2024 7HI430HI5 2021 – 2024 7HIHI7F1003 2022 – 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of four processing centers out of the Department’s 20 processing centers and noted that supervisor reviews over DHS Form 1494, Form 1495, and/or DHS Form 1050 were not properly performed at two processing centers. A similar finding was reported in the prior year as Finding No. 2023 003. Criteria Pursuant to 7 CFR 274.8(b)(3), the Department is required to ensure there are storage and control measures to control blank unissued electronic benefit transfer (“EBT”) cards. To address this requirement, the Department has adopted a policy that requires (1) monthly or quarterly review of the Department Form 1494, Bulk Inventory Control Log; (2) daily or weekly review of the Department Form 1495, Hawaii EBT Card Daily Control Log; and (3) monthly review of the Department Form 1050, EBT Card Destruction Control Log. Effect Documentation of supervisor approval of the review over the Department Form 1494, Form 1495, and/or DHS Form 1050 was not properly performed at two processing centers, increasing the risk of non compliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the personnel changes in the past years resulted in inconsistent application and documentation of supervisor reviews. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department periodically reviews the policies and procedures with the supervisors.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: In addition to our Electronic Benefit Transfer (“EBT”) Management Evaluations of the Processing Centers, which occur on a rotational basis of once every three years, the EBT Office will go out and visit in-person each Processing Center on Oahu, to do a spot check to ensure the Processing Centers are following the EBT Card Security Procedures on an annual basis. Also, for the Neighbor Island Processing Centers, the EBT Office will do a desk review of the DHS 1494, DHS 1495, and DHS 1050 forms and conduct a Teams Virtual Meeting with the Processing Center’s Supervisor(s) to ensure the EBT Card Security Procedures are being followed. In addition to EBT Management Evaluations, in person spot checks, and desk review with Virtual Team Meetings for Neighbor Island, the EBT Project Manager will make periodic reminder announcements for Processing Centers to adhere to the EBT Card Security Procedures at the monthly Joint Section Meetings to account for changes in staff that maybe new and not familiar with the EBT Card Security Procedures. Completion Date: June 2026 Responding Official(s): Sabrina Young, Benefit, Employment, and Support Services Division Electronic Benefit Transfer Project Manager
2023-003
Finding No. 2024 004: Special Tests and Provisions (Material Weakness) Questioned costs: $ - Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561 and COVID 19 – 10.561 – SNAP Cluster Award Number and Award Year: 7HI400HI4 2022 – 2024 7HI430HI4 2022 – 2024 7HI430HI5 2021 – 2024 7HIHI7F1003 2022 – 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 daily reconciliations for testing and noted 11 instances where variances were not investigated and there was no evidence that a review of the daily reconciliation was performed. The Department’s daily reconciliations identified variances totaling approximately $11.1 million. A similar finding was reported in the prior year as Finding No. 2023 004. Criteria Pursuant to 7 CFR 274.4, the Department is required to perform daily reconciliations of all SNAP transactions between the State’s Benefit Account, the U.S. Treasury Department, and all the EBT contractors. Effect Failure to resolve the reconciling items resulted in non compliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require a supervisor sign off documenting their review, resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliation is reviewed in a timely manner.
Show full finding ▾Hide full finding ▴Finding No. 2024 004: Special Tests and Provisions (Material Weakness) Questioned costs: $ - Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561 and COVID 19 – 10.561 – SNAP Cluster Award Number and Award Year: 7HI400HI4 2022 – 2024 7HI430HI4 2022 – 2024 7HI430HI5 2021 – 2024 7HIHI7F1003 2022 – 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 daily reconciliations for testing and noted 11 instances where variances were not investigated and there was no evidence that a review of the daily reconciliation was performed. The Department’s daily reconciliations identified variances totaling approximately $11.1 million. A similar finding was reported in the prior year as Finding No. 2023 004. Criteria Pursuant to 7 CFR 274.4, the Department is required to perform daily reconciliations of all SNAP transactions between the State’s Benefit Account, the U.S. Treasury Department, and all the EBT contractors. Effect Failure to resolve the reconciling items resulted in non compliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require a supervisor sign off documenting their review, resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliation is reviewed in a timely manner.
Views of Responding Officials: The Department agrees with the finding, will implement corrective action, and will work with the appropriate parties to address this issue. Corrective Action Taken or Planned: We have made requests to get more detailed reports from both Fidelity National Information Services (“FIS”) and the Office of Enterprise Technology (“OET”). FIS was able to provide us with the detailed reports, yet we are still working with OET to create a report that will give us similar information. We will also meet with both offices to discuss the information on these reports and from there, identify any variances that may be occurring. We will update our procedures to have the supervisor review and sign off on the daily reconciliations. Completion Date: June 2025 Responding Official(s): Joey Wong, Fiscal Management Office Accounting Supervisor
2023-004
Finding No. 2024-005: Special Tests and Provisions (Material Weakness) Questioned cost: $ 4,367 Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561 and COVID 19 – 10.561 – SNAP Cluster Award Number and Award Year: 7HI400HI4 2022 – 2024 7HI430HI4 2022 – 2024 7HI430HI5 2021 – 2024 7HIHI7F1003 2022 – 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $37,000 in monthly payments, out of a population of approximately 170,500 participant files which approximated $758 million in total annual benefit payments, for testing and noted exceptions in 12 case files as follows: • Three case files where manually entered income and deduction amounts did not agree with the documentation retained in the participant’s case file. • Five case files where manually entered deduction amounts did not agree with the documentation retained in the participant’s case file. • Four case files where manually entered income information did not agree with the documentation retained in the respective participant’s case files. A similar finding was reported in the prior year as Finding No. 2023 005. Criteria Pursuant to 7 CFR 272.10(b)(1)(i), the SNAP system should be efficiently automated to determine eligibility and calculate benefits or validate the eligibility of the worker’s calculations by processing and storing all case file information necessary for the eligibility determination and benefit computation (including but not limited to all household members’ names, addresses, dates of birth, social security numbers, individual household members’ earned and unearned income by source, deductions, resources, and household size). Effect Participants received more or less than the full amount of benefits they were eligible for, resulting in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant’s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually.
Show full finding ▾Hide full finding ▴Finding No. 2024-005: Special Tests and Provisions (Material Weakness) Questioned cost: $ 4,367 Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561 and COVID 19 – 10.561 – SNAP Cluster Award Number and Award Year: 7HI400HI4 2022 – 2024 7HI430HI4 2022 – 2024 7HI430HI5 2021 – 2024 7HIHI7F1003 2022 – 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $37,000 in monthly payments, out of a population of approximately 170,500 participant files which approximated $758 million in total annual benefit payments, for testing and noted exceptions in 12 case files as follows: • Three case files where manually entered income and deduction amounts did not agree with the documentation retained in the participant’s case file. • Five case files where manually entered deduction amounts did not agree with the documentation retained in the participant’s case file. • Four case files where manually entered income information did not agree with the documentation retained in the respective participant’s case files. A similar finding was reported in the prior year as Finding No. 2023 005. Criteria Pursuant to 7 CFR 272.10(b)(1)(i), the SNAP system should be efficiently automated to determine eligibility and calculate benefits or validate the eligibility of the worker’s calculations by processing and storing all case file information necessary for the eligibility determination and benefit computation (including but not limited to all household members’ names, addresses, dates of birth, social security numbers, individual household members’ earned and unearned income by source, deductions, resources, and household size). Effect Participants received more or less than the full amount of benefits they were eligible for, resulting in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant’s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. The Supplemental Nutrition and Assistance Program office (“SNAPO”) has addressed these issues within the division to make efforts to improve our payment accuracy which include electronic case documentation and data entry accuracy. Corrective Action Taken or Planned: SNAPO has worked with Statewide Branch Administration (“SBA”) to address these types of deficiencies as Hawaii is presently under corrective action for payment error rates. A mandatory refresher training to address budgeting and household composition had been implemented starting in January 2024 to improve core eligibility fundamentals such as budgeting. SNAPO will share the findings provided from this audit to include this as a part of our broader corrective strategy being implemented across the division through the partnership of SNAPO and SBA to address root causes for these errors. Regular case reviews are planned on being conducted to address areas of concern and will be addressed accordingly through supervisory channels to improve payment accuracy and case documentation. Completion Date: This is an on going activity and started for planning purposes from December 2024. SNAPO and Statewide Branch will be implementing the inaugural training/review with the Quality Maintenance and their review of the Quality Control (“QC”) Reports from Audit, Quality Control and Research Office (“AQCRO”). The Quality Control office conduct monthly reviews of all SNAP cases to provide to USDA Food and Nutrition Services on payment errors and will notate administrative deficiencies such as incorrect data entry for both income and deduction amounts used to calculate benefits when determining SNAP eligibility. The regular review cadence is monthly for the QC reports with a tentative quarterly discussion on findings to determine further assistance that can be provided through a collaboration between SNAPO and Staff Development office with policy guidance and staff training. Responding Official(s): Ginet Hayes, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator
2023-005
Finding No. 2024 006: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 18,613 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.659 and COVID 19 – 93.659 – Adoption Assistance Award Number and Award Year: 2301HIADPT 2023 2401HIADPT 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximates $54,700 in monthly benefit payments, out of a population of approximately 1,359 case files which approximate $12.2 million in total annual benefit payments, for testing and noted exceptions in 33 case files as follows: • Thirteen case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • One case in which the payment was improperly loaded in the system causing a difference between the agreement amount and paid amount. • Six case files where the “difficulty of care” determination was missing and therefore did not have any support for the assistance amount paid. • Thirteen case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. • Seven case files where the supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents was missing. • Three case files where the documentation regarding the continuation of the monthly subsidy payments after the child’s 18th birthday was missing. A similar finding was reported in the prior year as Finding No. 2023 008. Criteria Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 675(3), the agreement for the adoption subsidy must be signed before the final decree of adoption and contain the information concerning the nature of services. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 673(c)(1), the State must determine whether the child cannot or should not be returned to the home of his or her parents. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents instances of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2024 006: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 18,613 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.659 and COVID 19 – 93.659 – Adoption Assistance Award Number and Award Year: 2301HIADPT 2023 2401HIADPT 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximates $54,700 in monthly benefit payments, out of a population of approximately 1,359 case files which approximate $12.2 million in total annual benefit payments, for testing and noted exceptions in 33 case files as follows: • Thirteen case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • One case in which the payment was improperly loaded in the system causing a difference between the agreement amount and paid amount. • Six case files where the “difficulty of care” determination was missing and therefore did not have any support for the assistance amount paid. • Thirteen case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. • Seven case files where the supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents was missing. • Three case files where the documentation regarding the continuation of the monthly subsidy payments after the child’s 18th birthday was missing. A similar finding was reported in the prior year as Finding No. 2023 008. Criteria Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 675(3), the agreement for the adoption subsidy must be signed before the final decree of adoption and contain the information concerning the nature of services. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 673(c)(1), the State must determine whether the child cannot or should not be returned to the home of his or her parents. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents instances of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Child Welfare Services (“CWS”) recognizes that licensing case files from neighbor islands (Maui, West Hawaii, and Kauai) came late or not at all, and this lack of ability to review the records significantly contributed to the errors. Moving forward, CWS will ensure easier records identification by geographical location and begin the neighbor island’s audits first, allowing extra time for records travel to review site. CWS also notes that additional communication and information sharing with auditors would have been helpful to ensure understanding of expectations prior to on site audit. The communications requested would resemble a pre audit information sharing call, an on site audit entry meeting with key agency staff, and an audit exit conference to discuss findings before the final report is generated. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Providing requested records in advance of the audit, B. Diligent compliance with policies and procedures, C. Supervisor coaching, support and review of records/documents for completeness, D. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staff are securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated, and ensuring it is filed in eligibility record. C. Locate or reprint and file missing “Certificate of Approvals.” D. Locate missing clearances in records not provided for review or re run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. E. Administrators to work with courts to ensure court orders contain the required language and are secured in a timely fashion. i. Secure missing termination of parental rights order. ii. Secure court order supporting “reasonable efforts.” iii. Secure missing police protective custody documentation or voluntary foster custody agreement for three cases. F. For young person(s) in Imua Kakou (“IK”) who turned 18 while in care. i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document (reason for) continuation of monthly subsidy payments after youth turned 18. 3. CWS has identified the Eligibility Unit (“FPPEU”) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staffs (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit, following checklist and secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information, and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. 7. In preparation for future audits, CWS will update the file identification and secure transport process as follows: A. MICU will send a separate email for records request to each neighbor island, identifying only their records, rather than sending a joint, multi-island, records request. B. The records request email sent by MICU will include a submittal deadline that will accommodate extra time for secured travel of records between islands to ensure all records arrive on time. C. MICU and Branch will review records submitted, ensuring that all records are available to the auditors for review. Completion Date: On going Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator
2023-008
Finding No. 2024 007: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 9,043 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.090 and COVID 19 – 93.090 – Guardianship Assistance Award Number and Award Year: 2301HIGARD 2023 2401HIGARD 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximated $46,100 in monthly benefit payments, out of a population of approximately 363 case files which approximated $3.0 million in total annual benefit payments, for testing and noted exceptions in 19 case files as follows: • Eight case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • Six case files where the “difficulty of care” determination was missing or did not match the amount paid and therefore did not have any support for the assistance amount paid. • Five case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing in the case files. A similar finding was reported in the prior year as Finding No. 2023 009. Criteria Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The “Guardianship/ Permanency Assistance Agreement” (“Agreement”) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department and includes the total amount of assistance payments. The Agreement may be further supplemented due to difficulties in caring for a child as determined by a caseworker on an as needed basis and documented on the “Difficulty of Care” (“DOC”) worksheet. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 671(a)(20)(C), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount, represent instances of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2024 007: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 9,043 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.090 and COVID 19 – 93.090 – Guardianship Assistance Award Number and Award Year: 2301HIGARD 2023 2401HIGARD 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximated $46,100 in monthly benefit payments, out of a population of approximately 363 case files which approximated $3.0 million in total annual benefit payments, for testing and noted exceptions in 19 case files as follows: • Eight case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • Six case files where the “difficulty of care” determination was missing or did not match the amount paid and therefore did not have any support for the assistance amount paid. • Five case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing in the case files. A similar finding was reported in the prior year as Finding No. 2023 009. Criteria Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The “Guardianship/ Permanency Assistance Agreement” (“Agreement”) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department and includes the total amount of assistance payments. The Agreement may be further supplemented due to difficulties in caring for a child as determined by a caseworker on an as needed basis and documented on the “Difficulty of Care” (“DOC”) worksheet. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 671(a)(20)(C), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount, represent instances of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. CWS recognizes that Licensing case files from neighbor islands (Maui, West Hawaii, and Kauai) came late or not at all, and this lack of ability to review the records significantly contributed to the errors. Moving forward, CWS will ensure easier records identification by geographical location and begin the neighbor island’s audits first, allowing extra time for records travel to review site. CWS also notes that additional communication and information sharing with auditors would have been helpful to ensure understanding of expectations prior to on site audit. The communications requested would resemble a pre audit information sharing call, an on site audit entry meeting with key agency staff, and an audit exit conference to discuss findings before the final report is generated. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Providing requested records in advance of the audit, B. Diligent compliance with policies and procedures, C. Supervisor coaching, support and review of records/documents for completeness, D. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staffs are securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated and ensuring filed in eligibility record. C. Locate or reprint and file missing “Certificate of Approvals.” D. Locate missing clearances in records not provided for review or re run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. E. Administrators to work with courts to ensure court orders contain the required language and are secured in a timely fashion. i. Secure missing termination of parental rights order. ii. Secure court order supporting “reasonable efforts.” iii. Secure missing police protective custody documentation or voluntary foster custody agreement for three cases. F. For young person(s) in Imua Kakou (“IK”) who turned 18 while in care. i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document (reason for) continuation of monthly subsidy payments after youth turned 18. 3. CWS has identified the Eligibility Unit (“FPPEU”) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staffs (Licensing, CWS and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit, following checklist and secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. 7. In preparation for future audits, CWS will update the file identification and secure transport process as follows: A. MICU will send a separate email for records request to each neighbor island, identifying only their records, rather than sending a joint, multi-island, records request. B. The records request email sent by MICU will include a submittal deadline that will accommodate extra time for secured travel of records between islands to ensure all records arrive on time. C. MICU and Branch will review records submitted, ensuring that all records are available to the auditors for review. Completion Date: On going Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator
2023-009
Finding No. 2024 008: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 10,905 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.658 and COVID 19 – 93.658 – Foster Care – Title IV E Award Number and Award Year: 2101HIFCGP 2019 2301HIFOST 2023 2401HIFOST 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximate $46,888 in monthly benefit payments, out of a population of approximately 452 case files which approximated $3.90 million in total annual benefit payments, for testing and noted exceptions in 23 case files as follows: • Four case files where the Police Protective Custody form or Voluntary Foster Custody Agreement was missing and therefore did not support whether the child was removed as part of a voluntary placement agreement or judicial determination. • Three case files where the Certificate of Approval was missing and therefore did not support whether the prospective foster parents were licensed. • Thirteen case files where the state, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. • Six case files where the “difficulty of care” determination was missing and therefore did not support the assistance amount paid. • One case file where the Judicial Determination was missing and therefore did not support the removal of the child was contrary to the welfare of the child, if DHS made reasonable efforts to prevent removal and finalize the permanency plan, and if the determination was within 60 days from removal. • One case file where the child’s IV E eligibility was not determined before implementing the foster care maintenance payments program provisions of the Title IV E plan. A similar finding was reported in the prior year as Finding No. 2023 010. Criteria Pursuant to 42 USC 672(a)(2), the State must determine whether the removal and foster care placement of a child was in accordance with a voluntary placement agreement or judicial determination. Pursuant to 42 USC 675(4)(A), the foster care maintenance payments should cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, and a child’s personal incidentals. Pursuant to 42 USC 672(c)(1)(A), a foster family home means the home of an individual family that is licensed or approved by the State in which it is situated as a foster family home that meets the standards established for the licensing or approval. Pursuant to 42 USC 671(a)(20)(A), any prospective foster parent must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases, before the foster parent may be finally approved for placement of a child. Pursuant to 45 CFR 1356.21(b), a Judicial Determination must determine reasonable efforts to prevent a child’s removal from the home, reasonable efforts to finalize a permanency plan, and circumstances in which reasonable efforts are not required to prevent a child’s removal from home to reunify the child and family, before the child is determined to be eligible under Title IV E. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents instances of noncompliance with the requirements above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2024 008: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 10,905 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.658 and COVID 19 – 93.658 – Foster Care – Title IV E Award Number and Award Year: 2101HIFCGP 2019 2301HIFOST 2023 2401HIFOST 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximate $46,888 in monthly benefit payments, out of a population of approximately 452 case files which approximated $3.90 million in total annual benefit payments, for testing and noted exceptions in 23 case files as follows: • Four case files where the Police Protective Custody form or Voluntary Foster Custody Agreement was missing and therefore did not support whether the child was removed as part of a voluntary placement agreement or judicial determination. • Three case files where the Certificate of Approval was missing and therefore did not support whether the prospective foster parents were licensed. • Thirteen case files where the state, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. • Six case files where the “difficulty of care” determination was missing and therefore did not support the assistance amount paid. • One case file where the Judicial Determination was missing and therefore did not support the removal of the child was contrary to the welfare of the child, if DHS made reasonable efforts to prevent removal and finalize the permanency plan, and if the determination was within 60 days from removal. • One case file where the child’s IV E eligibility was not determined before implementing the foster care maintenance payments program provisions of the Title IV E plan. A similar finding was reported in the prior year as Finding No. 2023 010. Criteria Pursuant to 42 USC 672(a)(2), the State must determine whether the removal and foster care placement of a child was in accordance with a voluntary placement agreement or judicial determination. Pursuant to 42 USC 675(4)(A), the foster care maintenance payments should cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, and a child’s personal incidentals. Pursuant to 42 USC 672(c)(1)(A), a foster family home means the home of an individual family that is licensed or approved by the State in which it is situated as a foster family home that meets the standards established for the licensing or approval. Pursuant to 42 USC 671(a)(20)(A), any prospective foster parent must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases, before the foster parent may be finally approved for placement of a child. Pursuant to 45 CFR 1356.21(b), a Judicial Determination must determine reasonable efforts to prevent a child’s removal from the home, reasonable efforts to finalize a permanency plan, and circumstances in which reasonable efforts are not required to prevent a child’s removal from home to reunify the child and family, before the child is determined to be eligible under Title IV E. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents instances of noncompliance with the requirements above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under the Criteria section above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. CWS recognizes that Licensing case files from neighbor islands (Maui, West Hawaii, and Kauai) came late or not at all, and this lack of ability to review the records significantly contributed to the errors. Moving forward, CWS will ensure easier records identification by geographical location and begin the neighbor island’s audits first, allowing extra time for records travel to review site. CWS also notes that additional communication and information sharing with auditors would have been helpful to ensure understanding of expectations prior to on site audit. The communications requested would resemble a pre audit information sharing call, an on site audit entry meeting with key agency staff, and an audit exit conference to discuss findings before the final report is generated. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Providing requested records in advance of the audit, B. Diligent compliance with policies and procedures, C. Supervisor coaching, support and review of records/documents for completeness, D. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated and ensuring filed in eligibility record. B. Locate or reprint and file missing “Certificate of Approvals.” C. Locate missing clearances in records not provided for review or re-run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. D. Administrators to work with courts to ensure court orders contain the required language and are secured in a timely fashion. i. Secure missing termination of parental rights order. ii. Secure court order supporting “reasonable efforts.” iii. Secure missing police protective custody documentation or voluntary foster custody agreement for three cases. E. For young person(s) in Imua Kakou (“IK”) who turned 18 while in care. i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document the reason for continuation of monthly subsidy payments after youth turned 18 or discontinue payment. 3. CWS has identified the Eligibility Unit (“FPPEU”) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staffs (Licensing, CWS and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit, following checklist and secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff may be given individual training or coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given individual training or coaching/supervisory support to correctly complete documentation. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. 7. In preparation for future audits, CWS will update the file identification and secure transport process as follows: A. MICU will send a separate email for records request to each neighbor island, identifying only their records, rather than sending a joint, multi-island, records request. B. The records request email sent by MICU will include a submittal deadline that will accommodate extra time for secured travel of records between islands to ensure all records arrive on time. C. MICU and Branch will review records submitted, ensuring that all records are available to the auditors for review. Completion Date: On going Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator
2023-010
Finding No. 2024 009: Reporting (Significant Deficiency) $ - Federal Agency: U.S. Department of Education AL Number and Title: 84.126 – Rehabilitation Services – Vocational Rehabilitation Grants to States Award Number and Award Year: H126A220015 2021 – 2024 H126A230015 2022 – 2024 H126A240015 2023 – 2024 Repeat Finding? No Condition We selected a non statistical sample of 60 participant case files, out of a population of 4,419 based on participants from two quarterly reports, for testing and noted the following: • One participant tested had discrepancies between the start date of employment in primary occupation per the case management system and per the supporting documentation. Criteria Pursuant to Rehabilitation Services Administration Policy Directive RSA PD 19 03 and 34 CFR 361.47, State Vocational Rehabilitation agencies are required to maintain supporting documentation (either hard copies or scanned copies) particularly regarding eligibility determinations, development of the individualized plan for employment, services period, and case closure in the service record or case management system. Data reported in the case management system must match the supporting documentation for data elements containing critical information. Effect Without the appropriate documentation to support the key data elements reported, the Department is unable to demonstrate its compliance with the reporting requirements. Cause and View of Responsible Officials Although the Department has policies and procedures in place to ensure that the supporting documents are maintained, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements.
Show full finding ▾Hide full finding ▴Finding No. 2024 009: Reporting (Significant Deficiency) $ - Federal Agency: U.S. Department of Education AL Number and Title: 84.126 – Rehabilitation Services – Vocational Rehabilitation Grants to States Award Number and Award Year: H126A220015 2021 – 2024 H126A230015 2022 – 2024 H126A240015 2023 – 2024 Repeat Finding? No Condition We selected a non statistical sample of 60 participant case files, out of a population of 4,419 based on participants from two quarterly reports, for testing and noted the following: • One participant tested had discrepancies between the start date of employment in primary occupation per the case management system and per the supporting documentation. Criteria Pursuant to Rehabilitation Services Administration Policy Directive RSA PD 19 03 and 34 CFR 361.47, State Vocational Rehabilitation agencies are required to maintain supporting documentation (either hard copies or scanned copies) particularly regarding eligibility determinations, development of the individualized plan for employment, services period, and case closure in the service record or case management system. Data reported in the case management system must match the supporting documentation for data elements containing critical information. Effect Without the appropriate documentation to support the key data elements reported, the Department is unable to demonstrate its compliance with the reporting requirements. Cause and View of Responsible Officials Although the Department has policies and procedures in place to ensure that the supporting documents are maintained, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: We are actively addressing this issue while highlighting the Division of Vocational Rehabilitation’s (“DVR’s”) high compliance rate of 98.3 percent. The Vocational Rehabilitation Specialist (“VRS”) and the Vocational Rehabilitation Manager have been thoroughly informed about the correct data entries required for Service E (work experiences while in Service status). It’s essential to note that “competitive integrated employment” must not be selected for Service E status. Instead, staff should choose alternatives such as “internships, whether paid or unpaid,” or “transitional employment” to ensure accurate data recording and prevent the inclusion of data element 350. Additionally, “competitive integrated employment” requires the client to be actively employed in alignment with their employment goal outlined in their Individualized Plan for Employment with a stable employment value date entered in the employment record. To assist our staff in this process, the Aware-System Bulletin will include a clear reminder to verify both the employment status and the stable employment value date for each case. Instructions for using the managed layout edit checker will also be provided, equipping staff with the necessary tools to identify errors and make corrections independently. The VRS will ensure that the Service E or Employed status aligns appropriately with the appropriate employment categories. This corrective action reinforces best practices and significantly improves staff compliance with the accuracy of our data from DVR’s case management system. Completion Date: On going monitoring and training as needed. Responding Official(s): Lea Dias, Vocational Rehabilitation Administrator and R. Pascual-Kestner, Vocational Rehabilitation Assistant Administrator
Finding No. 2024 010: Eligibility (Material Weakness) Questioned cost: $ 1,787 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 – Temporary Assistance for Needy Families (“TANF”) Award Number and Award Year: 1402HITAN3 2014 – 2023 1402HITANF 2014 – 2023 1601HITAN3 2016 – 2023 1601HITANF 2016 – 2023 1701HITANF 2017 – 2023 1701HITAN3 2017 – 2023 2201HITANF 2022 – 2023 2301HITANF 2023 – 2023 2401HITANF 2023 – 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 participant files, representing approximately $35,500 of monthly benefit payments, out of a population of approximately 3,700 cases, representing approximately $40.1 million of benefit payments, for testing and noted exceptions in four case files as follows: • One case file where the benefit payment was incorrectly calculated. • Three case files where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. A similar finding was reported in the prior year as Finding No. 2023 016. Criteria The State of Hawaii TANF State Plan states that a review of all eligibility requirements is required every 12 months for all TANF households. The State Plan also states that for the Department to make a decision regarding an applicant’s eligibility, an interview must be conducted with the applicant no later than forty-five (45) days after the application is received. Effect Failure to follow the established procedures in place over the eligibility determination process resulted in non-compliance with the requirement and questioned costs. Cause and View of Responsible Officials The Department has a history of backlogged cases, which does not allow them to work on current issues when they arise. Recommendation We recommend that the Department work with Administration for Children and Families to determine what remediation actions, if any, are required.
Show full finding ▾Hide full finding ▴Finding No. 2024 010: Eligibility (Material Weakness) Questioned cost: $ 1,787 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 – Temporary Assistance for Needy Families (“TANF”) Award Number and Award Year: 1402HITAN3 2014 – 2023 1402HITANF 2014 – 2023 1601HITAN3 2016 – 2023 1601HITANF 2016 – 2023 1701HITANF 2017 – 2023 1701HITAN3 2017 – 2023 2201HITANF 2022 – 2023 2301HITANF 2023 – 2023 2401HITANF 2023 – 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 participant files, representing approximately $35,500 of monthly benefit payments, out of a population of approximately 3,700 cases, representing approximately $40.1 million of benefit payments, for testing and noted exceptions in four case files as follows: • One case file where the benefit payment was incorrectly calculated. • Three case files where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. A similar finding was reported in the prior year as Finding No. 2023 016. Criteria The State of Hawaii TANF State Plan states that a review of all eligibility requirements is required every 12 months for all TANF households. The State Plan also states that for the Department to make a decision regarding an applicant’s eligibility, an interview must be conducted with the applicant no later than forty-five (45) days after the application is received. Effect Failure to follow the established procedures in place over the eligibility determination process resulted in non-compliance with the requirement and questioned costs. Cause and View of Responsible Officials The Department has a history of backlogged cases, which does not allow them to work on current issues when they arise. Recommendation We recommend that the Department work with Administration for Children and Families to determine what remediation actions, if any, are required.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Temporary Assistance for Needy Families (“TANF”) Program Office will continue to issue reminders to the eligibility staff, focusing on specific topics and common errors such as, but not limited to, incorrect calculations, policy applications, and determinations. The division has implemented a strategy to address the backlog which caused some TANF applications to be processed beyond the 45 day timeframe. The strategy includes dedicating a group of eligibility staff to the statewide call center where most applicants and recipients are requested to call to complete their eligibility interviews. Completion Date: December 31, 2025 Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2023-016
Finding No. 2024 011: Reporting, Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 714 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014 – 2023 1402HITANF 2014 – 2023 1601HITAN3 2016 – 2023 1601HITANF 2016 – 2023 1701HITANF 2017 – 2023 1701HITAN3 2017 – 2023 2201HITANF 2022 – 2023 2301HITANF 2023 – 2023 2401HITANF 2023 – 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 participants for testing out of a population of approximately 3,500 participants whose work participation activity was reported on the ACF 199 and noted exceptions with three participants as follows: • We noted one instance where an eligible work participant was participating, but the Department did not retain a supporting paystub. • We noted one instance where an eligible work participant was participating, but the hours in the eligibility system did not match the supporting paystub. • We noted one instance where a work eligible participant did not comply with their work participation plan, but the Department inaccurately reported the corresponding participant as required to participate and participating but not meeting minimum participation requirements. A similar finding was reported in the prior year as Finding No. 2023 014. Criteria Pursuant to 45 CFR 265.3(b)(1), on a quarterly basis, the Department is required to submit disaggregated information on families receiving TANF benefits, which includes demographic data such as work participation activities. Effect Failure to report accurate work participation information limits the Department’s ability to demonstrate compliance with the requirement and could result in non compliance with the minimum work participation rate requirements. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2024 011: Reporting, Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 714 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014 – 2023 1402HITANF 2014 – 2023 1601HITAN3 2016 – 2023 1601HITANF 2016 – 2023 1701HITANF 2017 – 2023 1701HITAN3 2017 – 2023 2201HITANF 2022 – 2023 2301HITANF 2023 – 2023 2401HITANF 2023 – 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 participants for testing out of a population of approximately 3,500 participants whose work participation activity was reported on the ACF 199 and noted exceptions with three participants as follows: • We noted one instance where an eligible work participant was participating, but the Department did not retain a supporting paystub. • We noted one instance where an eligible work participant was participating, but the hours in the eligibility system did not match the supporting paystub. • We noted one instance where a work eligible participant did not comply with their work participation plan, but the Department inaccurately reported the corresponding participant as required to participate and participating but not meeting minimum participation requirements. A similar finding was reported in the prior year as Finding No. 2023 014. Criteria Pursuant to 45 CFR 265.3(b)(1), on a quarterly basis, the Department is required to submit disaggregated information on families receiving TANF benefits, which includes demographic data such as work participation activities. Effect Failure to report accurate work participation information limits the Department’s ability to demonstrate compliance with the requirement and could result in non compliance with the minimum work participation rate requirements. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Temporary Assistance for Needy Families (“TANF”) Program Office will collaborate with the division’s Staff Development Office to develop “refresher” training modules on the Benefit, Employment, and Support Services Division (“BESSD”) Learning Academy. Each training module will focus on a specific topic of concern. To monitor staff’s completion of the training modules and their progress, each module will include a quiz or test at the end that staff will be required to complete and pass (e.g., pass equates to a score of 80% and higher). The TANF Program Office and the Staff Development Office began discussions on February 26, 2025. Completion Date: December 31, 2025 Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2023-014
Finding No. 2024 012: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 405 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014 – 2023 1402HITANF 2014 – 2023 1601HITAN3 2016 – 2023 1601HITANF 2016 – 2023 1701HITANF 2017 – 2023 1701HITAN3 2017 – 2023 2201HITANF 2022 – 2023 2301HITANF 2023 – 2023 2401HITANF 2023 – 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files for testing and noted one instance where the Department’s records did not support the use of the income information obtained through the Income Eligibility and Verification System (“IEVS”) to evaluate or re evaluate the benefit calculation. A similar finding was reported in the prior year as Finding No. 2023 011. Criteria Pursuant to 45 CFR 205.55, the Department is required to request through the IEVS system, wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Effect Failure to properly use IEVS information to evaluate benefit amounts resulted in potential over payment of benefits. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2024 012: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 405 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014 – 2023 1402HITANF 2014 – 2023 1601HITAN3 2016 – 2023 1601HITANF 2016 – 2023 1701HITANF 2017 – 2023 1701HITAN3 2017 – 2023 2201HITANF 2022 – 2023 2301HITANF 2023 – 2023 2401HITANF 2023 – 2024 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files for testing and noted one instance where the Department’s records did not support the use of the income information obtained through the Income Eligibility and Verification System (“IEVS”) to evaluate or re evaluate the benefit calculation. A similar finding was reported in the prior year as Finding No. 2023 011. Criteria Pursuant to 45 CFR 205.55, the Department is required to request through the IEVS system, wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Effect Failure to properly use IEVS information to evaluate benefit amounts resulted in potential over payment of benefits. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department does not agree with this finding. According to 45 CFR section 205.55, it states, “…the State agency will request through the Income Eligibility and Verification System (“IEVS”)…”. However, the policy does not specify the State agency must “properly use IEVS information to evaluate benefit amounts…” as notated in this finding under “Effect.” Unless IEVS provides the necessary information for the applicable benefit month(s) used to determine a TANF applicant’s or recipient’s (“client”) eligibility, information obtained through IEVS will only validate whether a household received an income source, after the fact, but will not verify the dollar amount. Hard-copy verification is obtained from the client to verify income source and dollar amount, for the applicable benefit months, to determine eligibility in accordance with §17 676-51, Hawaii Administrative Rules. For example, if a client applied for TANF on February 28, 2025, and the department processes the application on March 20, 2025 (current month), verification of the household’s income received in February 2025 and received thus far in March 2025, must be obtained to determine eligibility for the month of application (February 2025) and subsequent months (based on projected income). Data obtained from IEVS are not current; therefore, if the information obtained from IEVS is used to determine eligibility, then we would violate our own administrative policy (i.e., §17 676-51, Hawaii Administrative Rules). For example, wage information through SWICA becomes available on a quarterly basis. The most current SWICA information available would have been for quarter ending December 31, 2024, for an application received on February 28, 2025, that was processed on March 20, 2025. Eligibility determination would have been improperly made if SWICA information from IEVS was applied. Corrective Action Taken or Planned: The department will continue to conduct IEVS check. The information obtained will only be used to validate a source of income reported by the applicant/client IF the information is applicable. Completion Date: On going Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2023-011
Finding No. 2024 013: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 3,846,999 Federal Agency: Department of Health and Human Services AL Number and Title: 93.777, 93.778 and COVID-19 – 93.778 – Medicaid Cluster Award Number and Award Year: 2305HIMAP 2023 2405HIMAP 2024 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,351 providers. The providers selected for testing represented approximately $135 million of payments out of a total payment population of $258 million. We identified two providers where the DHS Form 1139 did not support revalidation within the most recent five year period. A similar finding was reported in the prior year as Finding No. 2023 007. Criteria Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents instances of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Show full finding ▾Hide full finding ▴Finding No. 2024 013: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 3,846,999 Federal Agency: Department of Health and Human Services AL Number and Title: 93.777, 93.778 and COVID-19 – 93.778 – Medicaid Cluster Award Number and Award Year: 2305HIMAP 2023 2405HIMAP 2024 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,351 providers. The providers selected for testing represented approximately $135 million of payments out of a total payment population of $258 million. We identified two providers where the DHS Form 1139 did not support revalidation within the most recent five year period. A similar finding was reported in the prior year as Finding No. 2023 007. Criteria Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents instances of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department has engaged with a vendor to implement our new online provider enrollment system HOKU on August 3, 2020 and started the process to have all providers re register their information in the new online system. Most providers were given a deadline to do this by December 31, 2023 and if missed they would be terminated in 2024. There are a few providers who did not re register by December 31, 2023, and these were primarily providers of exclusive or specific services who refused to enroll into HOKU. Not enrolling these providers will have a disruptive impact to the service delivery experience and greatly increase the costs to the program, by risking the Department having to send additional patients to the mainland to get the specialized medical care needed. The Department will be terminating these remaining providers by December 31, 2025. Additionally, the Department is planning to apply for an 1115 demonstration waiver amendment in 2025, to waive the 42 CFR 455.414 provider enrollment requirements for these few providers with exclusive services. Completion Date: December 31, 2025 Responding Official(s): Marvin Malohi, Med-QUEST Division, Supervising Contracts Specialist
2023-007
Finding No. 2024 014: Eligibility (Significant Deficiency) Questioned cost: $ 1,087 Federal Agency: Department of Health and Human Services AL Number and Title: 93.777, 93.778 and COVID-19 – 93.778 – Medicaid Cluster Award Number and Award Year: 2305HIMAP 2023 2405HIMAP 2024 Repeat Finding? No Condition During our audit, we selected a non statistical sample of 60 individuals for testing out of a population of approximately 469,538 enrollments. The enrollments selected for testing represented approximately $280,000 of payments out of a total payment population of $3.4 billion. We identified one enrollment whose benefits were not timely terminated after failing to provide verification to support revalidation. Criteria Title 42 CFR Part 435.912 requires the timely determination of eligibility of individuals who apply for Medicaid benefits within (1) 90 days for applicants who apply for Medicaid on the basis of disability (MAGI-excepted), and (2) 45 days for all other applicants (MAGI). In addition, Title 42 CFR Part 435.916 requires annual re verifications of participant eligibility. Effect Failure to follow the established policies and procedures in place over the Medicaid eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department implement training and standard operating procedures to ensure eligibility determinations are completed in a timely manner.
Show full finding ▾Hide full finding ▴Finding No. 2024 014: Eligibility (Significant Deficiency) Questioned cost: $ 1,087 Federal Agency: Department of Health and Human Services AL Number and Title: 93.777, 93.778 and COVID-19 – 93.778 – Medicaid Cluster Award Number and Award Year: 2305HIMAP 2023 2405HIMAP 2024 Repeat Finding? No Condition During our audit, we selected a non statistical sample of 60 individuals for testing out of a population of approximately 469,538 enrollments. The enrollments selected for testing represented approximately $280,000 of payments out of a total payment population of $3.4 billion. We identified one enrollment whose benefits were not timely terminated after failing to provide verification to support revalidation. Criteria Title 42 CFR Part 435.912 requires the timely determination of eligibility of individuals who apply for Medicaid benefits within (1) 90 days for applicants who apply for Medicaid on the basis of disability (MAGI-excepted), and (2) 45 days for all other applicants (MAGI). In addition, Title 42 CFR Part 435.916 requires annual re verifications of participant eligibility. Effect Failure to follow the established policies and procedures in place over the Medicaid eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department implement training and standard operating procedures to ensure eligibility determinations are completed in a timely manner.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Upon further review of the case, it was determined that the caseworker processed the case in “Manual Eligibility” mode which prevented the Kauhale On Line Eligibility Assistance System (“KOLEA”) from terminating benefits. Another worker removed “Manual Eligibility” mode in January enabling KOLEA to process the case and send a termination notice. The worker should have processed the case and taken the case out of “Manual Eligibility” mode when case processing was complete. Corrective Action Taken or Planned: The “Eligibility Determination” training module will be updated to include additional instructions for Manual Actions in the Kauhale On Line Eligibility Assistance System (“KOLEA”). Workers will be instructed to seek guidance from a supervisor for next steps, before running a case manually. This training will be provided on April 30, 2025, to all supervisors and caseworkers and will include a Participant Guide and a summary of the change. To ensure that the training was effective, a query will be run of all cases that are set to “manual,” including the date in which the case was placed in manual. Med-QUEST Division (“MQD”) will review all identified cases to determine if the case should remain in manual for any legitimate eligibility reason. Completion Date: April 30, 2025 Responding Official(s): Lori Lei Aponte, Med-QUEST Division, Eligibility Branch Administrator
FAC accepted this audit on April 1, 2024 — management decision was due October 1, 2024.
Finding No. 2023 003: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ - Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 – 10.561 – Supplemental Nutrition Assistance Program (“SNAP”) Cluster Award Number and Award Year: 7HI4HIS8036 2021 – 2022 7HI400HI4 2020-2023 7HI430HI4 2021-2023 7HI400HI5 2020-2022 7HI430HI5 2021-2023 7HIHI7F1003 2021-2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of four processing centers out of the Department’s 21 processing centers and noted that evidence of supervisor reviews over DHS Form 1494, DHS Form 1495, and/or DHS Form 1050 was not maintained at two processing centers. Criteria Pursuant to 7 CFR 274.8(b)(3), the Department is required to ensure there are storage and control measures to control blank unissued electronic benefit transfer (“EBT”) cards. To address this requirement, the Department has adopted a policy that requires (1) monthly or quarterly review of the DHS Form 1494, Bulk Inventory Control Log; (2) daily or weekly review of the DHS Form 1495, Hawaii EBT Card Daily Control Log; and (3) monthly review of the DHS Form 1050, EBT Card Destruction Control Log. Effect Documentation of supervisor approval of the review over DHS Form 1494, DHS Form 1495, and/or DHS Form 1050 was not maintained at two processing centers, increasing the risk of noncompliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, there was a lack of diligence in following the Department’s established policies and procedures resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Show full finding ▾Hide full finding ▴Finding No. 2023 003: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ - Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 – 10.561 – Supplemental Nutrition Assistance Program (“SNAP”) Cluster Award Number and Award Year: 7HI4HIS8036 2021 – 2022 7HI400HI4 2020-2023 7HI430HI4 2021-2023 7HI400HI5 2020-2022 7HI430HI5 2021-2023 7HIHI7F1003 2021-2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of four processing centers out of the Department’s 21 processing centers and noted that evidence of supervisor reviews over DHS Form 1494, DHS Form 1495, and/or DHS Form 1050 was not maintained at two processing centers. Criteria Pursuant to 7 CFR 274.8(b)(3), the Department is required to ensure there are storage and control measures to control blank unissued electronic benefit transfer (“EBT”) cards. To address this requirement, the Department has adopted a policy that requires (1) monthly or quarterly review of the DHS Form 1494, Bulk Inventory Control Log; (2) daily or weekly review of the DHS Form 1495, Hawaii EBT Card Daily Control Log; and (3) monthly review of the DHS Form 1050, EBT Card Destruction Control Log. Effect Documentation of supervisor approval of the review over DHS Form 1494, DHS Form 1495, and/or DHS Form 1050 was not maintained at two processing centers, increasing the risk of noncompliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, there was a lack of diligence in following the Department’s established policies and procedures resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The two processing centers that did not document the supervisor audits were using the wrong outdated forms that did not have the added column (03/2022) to document the audit took place. A reminder will be sent out to Branch, Section Administrators, and all Processing Center Supervisors to instruct the Processing Centers to use the DHS 1494, 1495 and 1050 forms dated 03/2022, which clearly instructs the Supervisors to date and initial the last column of the form to verify when and by whom the audit took place. Expected Completion Date: March 2024 Responding Officials: Sabrina Young, EBT Project Manager
2022-017
Finding No. 2023 004 Special Tests and Provisions (Material Weakness) Questioned cost: $ – Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 – 10.561 – SNAP Cluster Award Number and Award Year: 7HI4HIS8036 2021 – 2022 7HI400HI4 2020-2023 7HI430HI4 2021-2023 7HI400HI5 2020-2022 7HI430HI5 2021-2023 7HIHI7F1003 2021-2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 daily reconciliations for testing and noted 12 instances where variances were not investigated and there was no evidence that a review of the daily reconciliation was performed. The Department’s daily reconciliations identified variances up to approximately $26.8 million. Criteria Pursuant to 7 CFR 274.4, the Department is required to perform daily reconciliations of all SNAP transactions between the State’s Benefit Account, the U.S. Treasury Department, and all the EBT contractors. Effect Failure to resolve the reconciling items resulted in noncompliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require supervisors to evidence their review resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliation is reviewed in a timely manner.
Show full finding ▾Hide full finding ▴Finding No. 2023 004 Special Tests and Provisions (Material Weakness) Questioned cost: $ – Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 – 10.561 – SNAP Cluster Award Number and Award Year: 7HI4HIS8036 2021 – 2022 7HI400HI4 2020-2023 7HI430HI4 2021-2023 7HI400HI5 2020-2022 7HI430HI5 2021-2023 7HIHI7F1003 2021-2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 daily reconciliations for testing and noted 12 instances where variances were not investigated and there was no evidence that a review of the daily reconciliation was performed. The Department’s daily reconciliations identified variances up to approximately $26.8 million. Criteria Pursuant to 7 CFR 274.4, the Department is required to perform daily reconciliations of all SNAP transactions between the State’s Benefit Account, the U.S. Treasury Department, and all the EBT contractors. Effect Failure to resolve the reconciling items resulted in noncompliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require supervisors to evidence their review resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliation is reviewed in a timely manner.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Fiscal Management Office will work with OIT to create a report to assist with reconciling the fiscal agent’s daily reports. Expected Completion Date: June 30, 2024 Responding Officials: Joey Wong, Fiscal Management Office Accountant
2022-006
Finding No. 2023 005: Special Tests and Provisions (Material Weakness) Questioned cost: $ 4,760 Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 – 10.561 – SNAP Cluster Award Number and Award Year: 7HI4HIS8036 2021 – 2022 7HI400HI4 2020-2023 7HI430HI4 2021-2023 7HI400HI5 2020-2022 7HI430HI5 2021-2023 7HIHI7F1003 2021-2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $51,000 in monthly payments, out of a population of approximately 183,000 participant files totaling $895 million in annual benefit payments, for testing and noted exceptions in six case files as follows: • Four case files where manually entered income and deduction amounts did not agree with the documentation retained in the participant’s case file. • Two case files where manually entered income information did not agree with the documentation retained in the respective participant’s case files. Criteria Pursuant to 7 CFR 272.10(b)(1)(i), the SNAP system should be efficiently automated to determine eligibility and calculate benefits or validate the eligible worker’s calculations by processing and storing all case file information necessary for the eligibility determination and benefit computation (including but not limited to all household members’ names, addresses, dates of birth, social security numbers, individual household members’ earned and unearned income by source, deductions, resources, and household size). Effect Participants did not receive the full amount of benefits they were eligible for, resulting in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant’s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually.
Show full finding ▾Hide full finding ▴Finding No. 2023 005: Special Tests and Provisions (Material Weakness) Questioned cost: $ 4,760 Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 – 10.561 – SNAP Cluster Award Number and Award Year: 7HI4HIS8036 2021 – 2022 7HI400HI4 2020-2023 7HI430HI4 2021-2023 7HI400HI5 2020-2022 7HI430HI5 2021-2023 7HIHI7F1003 2021-2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $51,000 in monthly payments, out of a population of approximately 183,000 participant files totaling $895 million in annual benefit payments, for testing and noted exceptions in six case files as follows: • Four case files where manually entered income and deduction amounts did not agree with the documentation retained in the participant’s case file. • Two case files where manually entered income information did not agree with the documentation retained in the respective participant’s case files. Criteria Pursuant to 7 CFR 272.10(b)(1)(i), the SNAP system should be efficiently automated to determine eligibility and calculate benefits or validate the eligible worker’s calculations by processing and storing all case file information necessary for the eligibility determination and benefit computation (including but not limited to all household members’ names, addresses, dates of birth, social security numbers, individual household members’ earned and unearned income by source, deductions, resources, and household size). Effect Participants did not receive the full amount of benefits they were eligible for, resulting in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant’s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Supplemental Nutrition and Assistance Program office has worked with Statewide Branch and Staff Development offices to address refresher training associated with budget calculations including the documentation and input of all data correctly. The Department is also in process of finalizing the new eligibility system – Benefit Eligibility Solution – slated to rollout statewide by late October 2024. As a condition of system rollout, all staff will be required to go through system training which will include a reinforcement of data entry practices and documentation requirements as a condition of eligibility determination. Expected Completion Date: October 31, 2024 Responding Officials: Ginet Hayes, Supplemental Nutrition and Assistance Administrator
2022-007
Finding No. 2023 006: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 4,574 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.767 – State Children’s Health Insurance Program Award Number and Award Year: 2205HI5022 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 2,010 providers. The providers selected for testing represented approximately $3.4 million of payments out of a total payment population of $7.0 million. We identified one provider where the DHS Form 1139 did not support revalidation within the most recent five-year period. Criteria Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Show full finding ▾Hide full finding ▴Finding No. 2023 006: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 4,574 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.767 – State Children’s Health Insurance Program Award Number and Award Year: 2205HI5022 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 2,010 providers. The providers selected for testing represented approximately $3.4 million of payments out of a total payment population of $7.0 million. We identified one provider where the DHS Form 1139 did not support revalidation within the most recent five-year period. Criteria Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: The Department has identified a gap in training and education, that caused a failure to enforce the contract requirements for plans to submit audited financial statements pursuant to 42 CFR 438.3(m). Training and education were completed. The Department has engaged with a vendor to implement our new online provider enrollment system HOKU on August 3, 2020 and started the process to have all providers re register their information in the new online system. All providers were given a deadline to do this by December 31, 2023 and if missed they would be terminated in 2024. Expected Completion Date: April 30, 2024 Responding Official: Marvin Malohi, Med-QUEST Division Supervising Contracts Specialist
2022-004
Finding No. 2023 007: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 16,525 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.777, 93.778, and COVID 19 – 93.778 – Medicaid Cluster Award Number and Award Year: 2205HIMAP 2022 2305HIMAP 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 2,010 providers. The providers selected for testing represented approximately $61 million of payments out of a total payment population of $234 million. We identified one provider where the DHS Form 1139 did not support revalidation within the most recent five-year period. Criteria Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Show full finding ▾Hide full finding ▴Finding No. 2023 007: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 16,525 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.777, 93.778, and COVID 19 – 93.778 – Medicaid Cluster Award Number and Award Year: 2205HIMAP 2022 2305HIMAP 2023 Repeat Finding? Yes Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 2,010 providers. The providers selected for testing represented approximately $61 million of payments out of a total payment population of $234 million. We identified one provider where the DHS Form 1139 did not support revalidation within the most recent five-year period. Criteria Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: The Department has identified a gap in training and education, that caused a failure to enforce the contract requirements for plans to submit audited financial statements pursuant to 42 CFR 438.3(m). Training and education were completed. The Department has engaged with a vendor to implement our new online provider enrollment system HOKU on August 3, 2020 and started the process to have all providers re register their information in the new online system. All providers were given a deadline to do this by December 31, 2023 and if missed they would be terminated in 2024. Expected Completion Date: April 30, 2024 Responding Official: Marvin Malohi, Med-QUEST Division Supervising Contracts Specialist
2022-002
Finding No. 2023 008: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 9,527 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.659 and COVID 19 – 93.659 – Adoption Assistance Award Number and Award Year: 2201HIADPT 2022 2301HIADPT 2023 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximated $44,000 in monthly benefit payments, out of a population of approximately 2,300 case files totaling $14.2 million in annual benefit payments, for testing and noted exceptions in 20 case files as follows: • 16 case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • Two case files where the State, Federal Bureau of Investigation (“FBI”), and/or child abuse and neglect clearances were missing. • Two case files where the “difficulty of care” determination was missing and therefore did not have any support for the assistance amount paid. • Four case files where the supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents was missing. • One case file where the final approval was granted to a household with an individual who was convicted of spousal abuse. • One case file where the adoption decree was missing from the case records. • One case file where the income eligibility test was missing from the case records. Criteria Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 671(a)(20)(B), the State shall check any child abuse and neglect registry maintained by the State for information on any prospective foster or adoptive parent and on any other adult living in the home of such a prospective parent. Pursuant to 42 USC 673(a)(2)(A), the State must determine the child to have special needs to be eligible for adoption assistance payments. Pursuant to 42 USC 673(c)(1), the State must determine whether the child cannot or should not be returned to the home of his or her parents. Pursuant to 42 USC 671(a)(20)(A)(i), in any case involving a child on whose behalf such payments are to be so made in which a record check reveals a felony conviction for spousal abuse, such final approval shall not be granted. Pursuant to 42 USC 675(3), the agreement for the adoption subsidy must be signed before the final decree of adoption and contains information concerning the nature of services. Pursuant to 42 USC 673(a)(2)(D), if an adopted child received Title IV E guardianship assistance payments, the Title IV E agency would apply the adoption assistance criteria for the child as if the guardianship never occurred. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2023 008: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 9,527 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.659 and COVID 19 – 93.659 – Adoption Assistance Award Number and Award Year: 2201HIADPT 2022 2301HIADPT 2023 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximated $44,000 in monthly benefit payments, out of a population of approximately 2,300 case files totaling $14.2 million in annual benefit payments, for testing and noted exceptions in 20 case files as follows: • 16 case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • Two case files where the State, Federal Bureau of Investigation (“FBI”), and/or child abuse and neglect clearances were missing. • Two case files where the “difficulty of care” determination was missing and therefore did not have any support for the assistance amount paid. • Four case files where the supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents was missing. • One case file where the final approval was granted to a household with an individual who was convicted of spousal abuse. • One case file where the adoption decree was missing from the case records. • One case file where the income eligibility test was missing from the case records. Criteria Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 671(a)(20)(B), the State shall check any child abuse and neglect registry maintained by the State for information on any prospective foster or adoptive parent and on any other adult living in the home of such a prospective parent. Pursuant to 42 USC 673(a)(2)(A), the State must determine the child to have special needs to be eligible for adoption assistance payments. Pursuant to 42 USC 673(c)(1), the State must determine whether the child cannot or should not be returned to the home of his or her parents. Pursuant to 42 USC 671(a)(20)(A)(i), in any case involving a child on whose behalf such payments are to be so made in which a record check reveals a felony conviction for spousal abuse, such final approval shall not be granted. Pursuant to 42 USC 675(3), the agreement for the adoption subsidy must be signed before the final decree of adoption and contains information concerning the nature of services. Pursuant to 42 USC 673(a)(2)(D), if an adopted child received Title IV E guardianship assistance payments, the Title IV E agency would apply the adoption assistance criteria for the child as if the guardianship never occurred. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, notes the following: Adoption Assistance is an incentive program with payment beginning prior to the finalization of an adoption. The adoption decree is not required for payment as the Adoption Assistance Agreement must be entered into prior to the finalization of an adoption. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Research/review and document why licensing approval was granted to a household with an individual who was convicted of spousal abuse. i. If review determines that Adoption Assistance Agreement (“AAA”) was inappropriately authorized, provide family with an adverse action notice discontinuing the AAA and explaining the appeals process. • Investigate whether supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents can be located and added to the record. • Secure a copy of the missing adoption decree, although adoption assistance is an incentive program with payment beginning prior to the finalization of an adoption. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Document how income eligibility was verified. • Secure missing modified adoption agreements. • Locate missing clearances or re run them if not located. Note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”), and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator, and Tonia Mahi, Social Services Division, Child Welfare Services Program Development Office, Assistant Branch Administrator
2022-008
Finding No. 2023 009: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 9,473 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.090 and COVID 19 – 93.090 – Guardianship Assistance Award Number and Award Year: 2201HIGARD 2022 2301HIGARD 2023 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximated $47,000 in monthly benefit payments, out of a population of approximately 375 case files totaling $3.9 million in annual benefit payments, for testing and noted exceptions in 21 case files as follows: • 17 case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • Two case files where the “difficulty of care” determination was missing and therefore did not have any support for the assistance amount paid. • Two case files where we were unable to determine if a child who attained the age of 14 was consulted regarding the kinship guardianship agreement. • One case file where the State, FBI, and/or child abuse and neglect clearances were missing in the case files. • One case file where documentation regarding continuation of monthly subsidy payments after the child’s 18th birthday was missing. Criteria Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The “Guardianship/ Permanency Assistance Agreement” (“Agreement”) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department and includes the total amount of assistance payments. The Agreement may be further supplemented due to difficulties in caring for a child as determined by a caseworker on an as needed basis and documented on the “Difficulty of Care” (“DOC”) worksheet. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 673(d)(3)(A), a child is eligible when the state agency determines the following: a) With respect to a child who has attained 14 years of age, the child has been consulted regarding the kinship guardianship arrangement. b) Eligible for foster care maintenance payments under 42 USC 672 while residing for at least six consecutive months in the home of the prospective relative guardian. c) Removed from his or her home pursuant to a voluntary placement agreement or as a result of a judicial determination to the effect that continuation in the home would be contrary to the welfare of the child. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Pursuant to 42 USC 671(a)(20)(c), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount, represent an instance of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements including compliance with 2 CFR Part 200. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2023 009: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 9,473 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.090 and COVID 19 – 93.090 – Guardianship Assistance Award Number and Award Year: 2201HIGARD 2022 2301HIGARD 2023 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximated $47,000 in monthly benefit payments, out of a population of approximately 375 case files totaling $3.9 million in annual benefit payments, for testing and noted exceptions in 21 case files as follows: • 17 case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. • Two case files where the “difficulty of care” determination was missing and therefore did not have any support for the assistance amount paid. • Two case files where we were unable to determine if a child who attained the age of 14 was consulted regarding the kinship guardianship agreement. • One case file where the State, FBI, and/or child abuse and neglect clearances were missing in the case files. • One case file where documentation regarding continuation of monthly subsidy payments after the child’s 18th birthday was missing. Criteria Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The “Guardianship/ Permanency Assistance Agreement” (“Agreement”) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department and includes the total amount of assistance payments. The Agreement may be further supplemented due to difficulties in caring for a child as determined by a caseworker on an as needed basis and documented on the “Difficulty of Care” (“DOC”) worksheet. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 673(d)(3)(A), a child is eligible when the state agency determines the following: a) With respect to a child who has attained 14 years of age, the child has been consulted regarding the kinship guardianship arrangement. b) Eligible for foster care maintenance payments under 42 USC 672 while residing for at least six consecutive months in the home of the prospective relative guardian. c) Removed from his or her home pursuant to a voluntary placement agreement or as a result of a judicial determination to the effect that continuation in the home would be contrary to the welfare of the child. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Pursuant to 42 USC 671(a)(20)(c), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount, represent an instance of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements including compliance with 2 CFR Part 200. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Secure a copy of the missing modified guardianship/permanency assistance agreement, demonstrating support for the monthly assistance paid. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Investigate whether the child who attained the age of 14 was consulted regarding the kinship guardianship agreement. Discuss this with the youth and document. • Locate missing clearances or re run them if not located, placing note in record about audit re run. Note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. • Secure documentation for case regarding continuation of monthly subsidy payments after the child’s 18th birthday. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”), and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on-going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator
2022-009
Finding No. 2023 010: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 5,248 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.658 and COVID 19 – 93.658 – Foster Care – Title IV E Award Number and Award Year: 2201HIFOST 2022 2301HIFOST 2023 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximated $43,000 in monthly benefit payments, out of a population of approximately 480 case files which totaled $4.89 million in annual benefit payments, for testing and noted exceptions in 11 case files as follows: • Three case files where the Police Protective Custody form or Voluntary Foster Custody Agreement was missing and therefore did not support whether the child was removed as part of a voluntary placement agreement or judicial determination. • Seven case files where the state, FBI, and/or child abuse and neglect clearances were missing. • One case file where the “difficulty of care” determination was missing and therefore did not support the assistance amount paid. • One case file where the Certificate of Approval was missing and therefore did not support whether the prospective foster parents were licensed. • One case file where the Judicial Determination was missing and therefore did not support the removal of the child was contrary to the welfare of the child, if DHS made reasonable efforts to prevent removal and finalize the permanency plan, and if the determination was within 60 days from removal. • One case file where the monthly meeting minutes for Imua Kakou were missing and therefore did not support the monthly meeting requirements at the option of the State. Criteria Pursuant to 42 USC 672(a)(2), the State must determine whether the removal and foster care placement of a child was in accordance with a voluntary placement agreement or judicial determination. Pursuant to 42 USC 675(4)(A), the foster care maintenance payments should cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, and a child’s personal incidentals. Pursuant to 42 USC 672(c)(1)(A), a foster family home means the home of an individual family that is licensed or approved by the State in which it is situated as a foster family home that meets the standards established for the licensing or approval. Pursuant to 42 USC 671(a)(20)(A), any prospective foster parent must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases, before the foster parent may be finally approved for placement of a child. Pursuant to 45 CFR 1356.21(b), a Judicial Determination must determine reasonable efforts to prevent a child’s removal from the home, reasonable efforts to finalize a permanency plan, and circumstances in which reasonable efforts are not required to prevent a child’s removal from home or to reunify the child and family, before the child is determined to be eligible under Title IV E. Pursuant to 42 USC 675(b)(8), a State may elect to continue benefits for a child who has reached 18 years of age (until 22 years of age) who is completing secondary education or a program leading to an equivalent credential; enrolled in an institution which provides post-secondary or vocational education; participating in a program or activity designed to promote, or remove barriers to, employment; employed for at least 80 hours per month; or incapable of doing any of the activities described in subclauses (I) through (IV) due to a medical condition, which incapability is supported by regularly updated information in the case plan of the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents instances of noncompliance with the requirements above resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2023 010: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Questioned cost: $ 5,248 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.658 and COVID 19 – 93.658 – Foster Care – Title IV E Award Number and Award Year: 2201HIFOST 2022 2301HIFOST 2023 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files which approximated $43,000 in monthly benefit payments, out of a population of approximately 480 case files which totaled $4.89 million in annual benefit payments, for testing and noted exceptions in 11 case files as follows: • Three case files where the Police Protective Custody form or Voluntary Foster Custody Agreement was missing and therefore did not support whether the child was removed as part of a voluntary placement agreement or judicial determination. • Seven case files where the state, FBI, and/or child abuse and neglect clearances were missing. • One case file where the “difficulty of care” determination was missing and therefore did not support the assistance amount paid. • One case file where the Certificate of Approval was missing and therefore did not support whether the prospective foster parents were licensed. • One case file where the Judicial Determination was missing and therefore did not support the removal of the child was contrary to the welfare of the child, if DHS made reasonable efforts to prevent removal and finalize the permanency plan, and if the determination was within 60 days from removal. • One case file where the monthly meeting minutes for Imua Kakou were missing and therefore did not support the monthly meeting requirements at the option of the State. Criteria Pursuant to 42 USC 672(a)(2), the State must determine whether the removal and foster care placement of a child was in accordance with a voluntary placement agreement or judicial determination. Pursuant to 42 USC 675(4)(A), the foster care maintenance payments should cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, and a child’s personal incidentals. Pursuant to 42 USC 672(c)(1)(A), a foster family home means the home of an individual family that is licensed or approved by the State in which it is situated as a foster family home that meets the standards established for the licensing or approval. Pursuant to 42 USC 671(a)(20)(A), any prospective foster parent must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases, before the foster parent may be finally approved for placement of a child. Pursuant to 45 CFR 1356.21(b), a Judicial Determination must determine reasonable efforts to prevent a child’s removal from the home, reasonable efforts to finalize a permanency plan, and circumstances in which reasonable efforts are not required to prevent a child’s removal from home or to reunify the child and family, before the child is determined to be eligible under Title IV E. Pursuant to 42 USC 675(b)(8), a State may elect to continue benefits for a child who has reached 18 years of age (until 22 years of age) who is completing secondary education or a program leading to an equivalent credential; enrolled in an institution which provides post-secondary or vocational education; participating in a program or activity designed to promote, or remove barriers to, employment; employed for at least 80 hours per month; or incapable of doing any of the activities described in subclauses (I) through (IV) due to a medical condition, which incapability is supported by regularly updated information in the case plan of the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents instances of noncompliance with the requirements above resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Locate Police Protective Custody form, Voluntary Foster Custody Agreement, or other documentation which clarifies whether the child was removed as part of a voluntary placement agreement or judicial determination. • Locate missing clearances or re-run them if not located, placing note in record about audit re run. Note: Not all clearances are secured prior to placement; FBI clearances come later and are not required prior to placement in a “provisionally licensed” home. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Review resource caregiver licensing status and locate missing license or reissue license. • Investigate the case where the Judicial Determination was missing and therefore did not support the removal of the child was contrary to the welfare of the child, if the Department made reasonable efforts to prevent removal and finalize the permanency plan, and if the determination was within 60 days from removal. i. Locate court order documenting “contrary to welfare” language, verifying timelines, place in record and document findings. • Locate missing Imua Kakou minutes or secure additional documentation validating monthly meeting requirement was met. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on-going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator
2022-015
Finding No. 2023 011: Special Tests and Provisions (Material Weakness) Questioned cost: $ 2,085 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – Temporary Assistance for Needy Families (“TANF”) Award Number and Award Year: 1402HITAN3 2014 – 2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020-2022 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files for testing and noted five instances where the Department’s records did not support the use of the income information obtained through Income Eligibility and Verification System (“IEVS”) to evaluate or re evaluate the benefit calculation. Criteria Pursuant to 45 CFR 205.55, the Department is required to request through the IEVS, wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Effect Failure to properly use IEVS information to determine eligibility and evaluate benefit amounts may result in potential overpayment of benefits to ineligible participants. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2023 011: Special Tests and Provisions (Material Weakness) Questioned cost: $ 2,085 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – Temporary Assistance for Needy Families (“TANF”) Award Number and Award Year: 1402HITAN3 2014 – 2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020-2022 Repeat Finding? Yes Condition We selected a non statistical sample of 60 case files for testing and noted five instances where the Department’s records did not support the use of the income information obtained through Income Eligibility and Verification System (“IEVS”) to evaluate or re evaluate the benefit calculation. Criteria Pursuant to 45 CFR 205.55, the Department is required to request through the IEVS, wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Effect Failure to properly use IEVS information to determine eligibility and evaluate benefit amounts may result in potential overpayment of benefits to ineligible participants. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department does not agree with this finding. According to 45 CFR section 205.55, it states, “…the State agency will request through the IEVS…”. However, the policy does not specify the State agency must “properly use IEVS information to evaluate benefit amounts…” as notated in this finding under “Effect.” Unless IEVS provides the necessary information for the applicable benefit month(s) used to determine a TANF applicant’s or recipient’s (“client”) eligibility, information obtained will only validate whether a household received an income source, after the fact, but will not verify the dollar amount. Hard-copy verification is obtained from the client to verify income source and dollar amount, for the applicable benefit months, to determine eligibility in accordance with §17 676 51, Hawaii Administrative Rules. For example, if a client applied for TANF on January 31, 2024, and the Department processes the application on February 29, 2024 (current month), verification of the household’s income received in January 2024 and received thus far in February 2024, must be obtained to determine eligibility for the month of application (January 2024) and subsequent months (based on projected income). Data obtained from IEVS are not current. For example, wage information through SWICA becomes available on a quarterly basis. The most current SWICA information available would have been for quarter ending December 31, 2023, for an application that was processed on February 29, 2024. Eligibility determination would have been improperly made if SWICA information was applied. Corrective Action Taken or Planned: The Department will continue to conduct IEVS check and utilize information obtained to determine eligibility if the information is applicable, otherwise, IEVS information will continue to be used to validate any source of income. Expected Completion Date: Ongoing Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator
2022-010
Finding No. 2023 012: Special Tests and Provisions (Material Weakness) Questioned cost: $ 19,748 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020 – 2022 Repeat Finding? Yes Condition We selected a non statistical sample of 10 participant files for testing out of a population of 99 participant files that were initially determined by the Title IV D agency as not cooperating with the child support enforcement requirements. We noted seven files did not contain any correspondence, notices or documentation to indicate whether any follow up action, up to and including case closure and cessation of benefits, were performed. Criteria Pursuant to 45 CFR 264.30, the Title IV A agency is required to take appropriate action, as defined, if the Title IV D agency determines that an individual is not cooperating with the child support enforcement requirements. Effect Failure to retain documentation to support a determination that appropriate action was taken limits the Department’s ability to demonstrate compliance with the requirement and resulted in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2023 012: Special Tests and Provisions (Material Weakness) Questioned cost: $ 19,748 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020 – 2022 Repeat Finding? Yes Condition We selected a non statistical sample of 10 participant files for testing out of a population of 99 participant files that were initially determined by the Title IV D agency as not cooperating with the child support enforcement requirements. We noted seven files did not contain any correspondence, notices or documentation to indicate whether any follow up action, up to and including case closure and cessation of benefits, were performed. Criteria Pursuant to 45 CFR 264.30, the Title IV A agency is required to take appropriate action, as defined, if the Title IV D agency determines that an individual is not cooperating with the child support enforcement requirements. Effect Failure to retain documentation to support a determination that appropriate action was taken limits the Department’s ability to demonstrate compliance with the requirement and resulted in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action, however, notes the following: The referrals to the Child Support Enforcement Agency (“CSEA”) are done through an interface between the HAWI eligibility and CSEA’s KEIKI systems. When a recipient is determined noncompliant by CSEA, the information is sent via the interface from KEIKI to HAWI in the form of a system-generated alert. This process worked well when application processing and maintenance of recipient cases were done in a case management method (e.g., each eligibility worker assigned to process applications and/or maintain a caseload of active cases). Using this method, eligibility workers managed their caseloads and checked for incoming alerts for cases assigned to them; these alerts included the CSEA noncompliant alerts coming from the KEIKI system. Workers were able to take appropriate and timely action in response to the alerts received. However, necessary changes were made to how applications and active cases are managed. The division stopped the case management method and converted to “task-oriented” processing statewide. Workers are no longer assigned to caseloads but are assigned to “tasks” such as processing applications, incoming documents/verifications, reported changes, six month review and annual recertifications, etc. A case is not reviewed and worked in HAWI until a worker is prompted to do so, e.g., six-month review, annual recertification or a change was reported by the household. It is until such action occurs when an eligibility worker, who picks up the task, will check for alerts for the case. Aside from that, recipient cases will not be reviewed during their certification period. So how the “alerts” were developed in HAWI no longer works for the way we currently process applications and maintain recipient cases. We are unable to modify the HAWI system because we are currently developing a new eligibility system that will replace HAWI. The new eligibility system is scheduled to go into production in late 2024. Corrective Action Taken or Planned: As an interim solution until the new eligibility system rolls out into production, a shared folder is being created where CSEA will place the monthly reports of non cooperating TANF cases so designated TANF staff members, who are granted access to the shared folder, will be able to retrieve the reports. TANFPO will review the identified TANF cases. Individual lists will be forwarded to the Section Administrators to instruct the affected Processing Centers to take appropriate action (i.e., TANF case closure due to noncompliance with CSEA). Expected Completion Date: July 1, 2024 Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator
2022-012
Finding No. 2023 013: Reporting (Material Weakness) Questioned cost: $ – Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020 – 2022 Repeat Finding? Yes Condition During our audit, we tested a non statistical sample of six subawards and found no evidence that the reporting required by Section 2, Full Disclosure of Entities Receiving Federal Funding, of the Federal Funding Accountability and Transparency Act (“FFATA”) was completed. Subawards not reported: 6 $1,775,000 Criteria Section 2, Full Disclosure of Entities Receiving Federal Funding, of the FFATA requires an entity to report subcontracts made under federally-awarded contracts by the end of the month following the month in which the prime recipient awards any subgrant greater than or equal to $30,000. Effect Failure to file required reports reduced transparency on the use of program funds and represents noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that the Department develop policies and procedures to ensure required FFATA reports are filed.
Show full finding ▾Hide full finding ▴Finding No. 2023 013: Reporting (Material Weakness) Questioned cost: $ – Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020 – 2022 Repeat Finding? Yes Condition During our audit, we tested a non statistical sample of six subawards and found no evidence that the reporting required by Section 2, Full Disclosure of Entities Receiving Federal Funding, of the Federal Funding Accountability and Transparency Act (“FFATA”) was completed. Subawards not reported: 6 $1,775,000 Criteria Section 2, Full Disclosure of Entities Receiving Federal Funding, of the FFATA requires an entity to report subcontracts made under federally-awarded contracts by the end of the month following the month in which the prime recipient awards any subgrant greater than or equal to $30,000. Effect Failure to file required reports reduced transparency on the use of program funds and represents noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that the Department develop policies and procedures to ensure required FFATA reports are filed.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Subawards will be entered into the FSRS within the appropriate timeframe following the execution of the contract. Expected Completion Date: Not applicable as reporting of federal subawards is an ongoing requirement. Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator
2022-013
Finding No. 2023 014: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 2,457 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020 – 2022 Repeat Finding? Yes Condition We selected a non statistical sample of 60 participants for testing out of a population of approximately 4,400 participants whose work participation activity was reported on the ACF 199 and noted exceptions with six participants as follows: • We noted one instance where a work eligible participant complied with their work participation plan, but the Department inaccurately reported the corresponding participant as noncompliant. • We noted three instances where a work eligible participant did not comply with their work participation plan, but the Department inaccurately reported the corresponding participants as not participating and not subject to sanction. • We noted one instance where a non work eligible participant was inaccurately excluded from the report. • We noted one instance where a work eligible participant did not comply with their work participation plan, but the Department inaccurately reported the corresponding participant as deemed engaged in work. Criteria Pursuant to 45 CFR 265.3(b)(1), on a quarterly basis, the Department is required to submit disaggregated information on families receiving TANF benefits, which includes demographic data such as work participation activities. Effect Failure to report accurate work participation information limits the Department’s ability to demonstrate compliance with the requirement and could result in noncompliance with the minimum work participation rate requirements. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2023 014: Special Tests and Provisions (Significant Deficiency) Questioned cost: $ 2,457 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020 – 2022 Repeat Finding? Yes Condition We selected a non statistical sample of 60 participants for testing out of a population of approximately 4,400 participants whose work participation activity was reported on the ACF 199 and noted exceptions with six participants as follows: • We noted one instance where a work eligible participant complied with their work participation plan, but the Department inaccurately reported the corresponding participant as noncompliant. • We noted three instances where a work eligible participant did not comply with their work participation plan, but the Department inaccurately reported the corresponding participants as not participating and not subject to sanction. • We noted one instance where a non work eligible participant was inaccurately excluded from the report. • We noted one instance where a work eligible participant did not comply with their work participation plan, but the Department inaccurately reported the corresponding participant as deemed engaged in work. Criteria Pursuant to 45 CFR 265.3(b)(1), on a quarterly basis, the Department is required to submit disaggregated information on families receiving TANF benefits, which includes demographic data such as work participation activities. Effect Failure to report accurate work participation information limits the Department’s ability to demonstrate compliance with the requirement and could result in noncompliance with the minimum work participation rate requirements. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. On March 4, 2024, during the process of making corrections to cases rejected by ACF, it was discovered that one of the jobs that uploads the current FTW file did not function properly resulting in the back up file for the previous month being used for the current report month. This resulted in incorrect work participation data reported on the ACF 199 for FFY 2023. Corrective Action Taken or Planned: Corrections are being made and the FFY 2023 ACF 199 reports are being re run. The final annual ACF 199 report for FFY 2023 will be resubmitted to ACF before the deadline of March 29, 2024. Expected Completion Date: March 29, 2024 Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator
2022-014
Finding No. 2023 015: Reporting (Material Weakness) Questioned costs: $ – Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020– 2022 Repeat Finding? Yes Condition The Department achieved a two parent work participation rate of 18%, which is below the federally mandated rate of 32.2%, calculated by subtracting the caseload reduction credit of 57.8% from the base 90.0%. Criteria Pursuant to 45 CFR 261.23, a State must achieve a 90% minimum two parent participation rate minus any caseload reduction credit to which it is entitled. Pursuant to 45 CFR 261.40(a)(2)(i), the minimum two parent participation rate the State must meet decreases by the number of percentage points the prior-year two parent caseload, including two parent cases receiving assistance under a separate State program, fell in comparison to the FY 2005 two parent caseload, including two parent cases receiving assistance under a separate State program. Effect Failure to meet the minimum two parent work participation rate may result in a reduction in the amount of State family assistance grants received. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2023 015: Reporting (Material Weakness) Questioned costs: $ – Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020– 2022 Repeat Finding? Yes Condition The Department achieved a two parent work participation rate of 18%, which is below the federally mandated rate of 32.2%, calculated by subtracting the caseload reduction credit of 57.8% from the base 90.0%. Criteria Pursuant to 45 CFR 261.23, a State must achieve a 90% minimum two parent participation rate minus any caseload reduction credit to which it is entitled. Pursuant to 45 CFR 261.40(a)(2)(i), the minimum two parent participation rate the State must meet decreases by the number of percentage points the prior-year two parent caseload, including two parent cases receiving assistance under a separate State program, fell in comparison to the FY 2005 two parent caseload, including two parent cases receiving assistance under a separate State program. Effect Failure to meet the minimum two parent work participation rate may result in a reduction in the amount of State family assistance grants received. Cause and View of Responsible Officials There was a lack of diligence in following the Department’s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Hawaii implemented an upfront work participation requirement as a condition of eligibility for TANF applicants beginning 2009. The purpose of the upfront work participation is to prepare applicant families to engage in the TANF work program. Our state temporarily amended its TANF State Plan in response to the COVID 19 pandemic, suspending the upfront work participation requirements, described in Part B, section 15.1, effective March 27, 2020. This suspension coupled with relaxed administrative policies for all means-tested programs which included TANF, Supplemental Nutrition Assistance Program, and our state-funded General Assistance and Aid to the Aged, Blind and Disabled, and operational changes statewide allowed the Department to process applications expeditiously ensuring eligible families have access to their financial assistance benefits quickly. In March 2020, Hawaii’s unemployment rate was as low as 2.2% (seasonally adjusted) but it increased considerably to 22.6% in April 2020 following the state’s first shut-down due to the COVID 19 pandemic. The state’s TANF caseload increased by about 177%, from March 2020 with 3,969 recipient families to 7,040 families in December 2020 following the state’s second shut-down. While the upfront work program participation was suspended as a condition of eligibility for TANF applicants, Hawaii still required recipients to participate with the work program after they were determined eligible for TANF benefits. The good cause provision was exercised judiciously and to the extent allowable under TANF federal regulations and Hawaii administrative rules. Our TANF work program extended its services to provide families the opportunities to receive additional support such as case management and counseling services; to access information and referrals to community resources such as housing assistance and food distribution events; and to receive assistance in navigating through programs, benefits, and services that our department and other government agencies have available during this period of economic downturn resulting from the health emergency. It was not until March 25, 2022, when then Governor David Y. Ige ended the state’s emergency proclamation relating to COVID 19. The Department continued to suspend the upfront work participation requirements through May 31, 2023, allowing a transition period to adjustour operations. The upfront work participation requirement as a condition of eligibility was reinstated for families who applied for TANF financial assistance benefits beginning June 1, 2022, with only four months remaining in the fiscal year. Other administrative policies that were temporarily suspended or amended in response to the pandemic were reinstated effective July 1, 2022. The public health emergency and heightened period of COVID 19 restrictions forced the Benefit, Employment and Support Services Division (“BESSD”), who oversees the TANF and other means-tested public assistance programs, to immediately modify its operations statewide, ensuring the continuity of its programs and services and making them more accessible to the public. It was important to provide BESSD a transition period to review its policies and operational procedures and allow its staff of over 650 employees to adjust after two years of operating programs and services in a manner that was unprecedented for the division. On January 17, 2024, the TANF program office met with the Statewide Branch Administration (“SBA”), who oversees the state First To-Work (“FTW”) program staff, to discuss the concerns regarding the work participation rates, active TANF recipients who were referred to FTW but not yet participating in the program, and strategies to address the concerns. Subsequently, on January 25, 2024, SBA held a meeting with the state FTW unit supervisors to share the concerns raised on the work participation rates and to solicit comments and suggestions. TANF program administrator and lead program specialist were in attendance to notate comments and suggestions. Corrective Action Taken or Planned: Pursuant to 45 CFR 262.5, the Department requested consideration for reasonable cause from the Administration for Children and Families (“ACF”), for not meeting the two parent work participation rate for fiscal year 2022. Response and determination from ACF is pending. The FTW unit supervisors were instructed, during the January 25, 2024 meeting, to invite and schedule the active TANF recipients, who were referred but not yet participating, to attend a work program orientation as soon as possible. It is expected that remaining active TANF recipients will be invited to the FTW program by March 31, 2024. TANF program office is exploring the suggestions received during the January 25, 2024 meeting with SBA and FTW unit supervisors. For example, it was suggested that the FTW program provide additional supportive service payments to participants, who are in countable non employment related work activities, to incentivize them to maintain their program engagement. However, this suggestion has a fiscal impact and will require the FTW program administrative rules to be amended before it can be implemented. The TANF program office plans to require both parents of two parent households to participate in the FTW program. Due to capacity issues of both state and contract staff, only one parent is required to participate and meet work program requirements for the TANF recipient household. The TANF caseloads have declined; therefore, capacity is no longer a concern. Expected Completion Date: March 31, 2025 Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator
2022-016
Finding No. 2023 016: Eligibility (Material Weakness) Questioned cost: $ 1,539 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020 – 2022 Repeat Finding? Yes Condition We selected a non statistical sample of 60 participant files, representing approximately $38,000 of benefit payments, out of a population of approximately 7,000 cases, representing approximately $15.8 million of benefit payments, for testing and noted exceptions in four case files as follows: • Two case files where benefit payments were incorrectly calculated. • Two case files where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. Criteria The TANF State Plan states that a review of all eligibility requirements is required every 12 months for all TANF households. The State Plan also states that for the Department to make a decision regarding an applicant’s eligibility, an interview must be conducted with the applicant no later than forty-five (45) days after the application is received. In addition, Administration for Children and Families (“ACF”) program instruction TANF ACF-PI 2020 01 indicates that States may make program changes but must submit a plan amendment within 30 days of the program changes. The program instruction recommends that the State seek guidance from ACF on whether a particular action is allowable under program requirements. Effect Failure to follow the established procedures in place over the eligibility determination process and to submit a plan amendment or to seek guidance from ACF on whether a particular action is allowable under program requirements, resulted in noncompliance with the requirement and questioned costs. Cause and View of Responsible Officials The Department has a history of backlogged cases, which does not allow them to work on current issue when they arise. Recommendation We recommend that the Department work with ACF to determine what remediation actions, if any, are required.
Show full finding ▾Hide full finding ▴Finding No. 2023 016: Eligibility (Material Weakness) Questioned cost: $ 1,539 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 – 93.558 – TANF Award Number and Award Year: 1402HITAN3 2014-2022 1601HITAN3 2016-2022 2101HITANF 2020-2022 2201HITANF 2021-2022 2301HITANF 2022-2023 2101HITANFC6 2020 – 2022 Repeat Finding? Yes Condition We selected a non statistical sample of 60 participant files, representing approximately $38,000 of benefit payments, out of a population of approximately 7,000 cases, representing approximately $15.8 million of benefit payments, for testing and noted exceptions in four case files as follows: • Two case files where benefit payments were incorrectly calculated. • Two case files where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. Criteria The TANF State Plan states that a review of all eligibility requirements is required every 12 months for all TANF households. The State Plan also states that for the Department to make a decision regarding an applicant’s eligibility, an interview must be conducted with the applicant no later than forty-five (45) days after the application is received. In addition, Administration for Children and Families (“ACF”) program instruction TANF ACF-PI 2020 01 indicates that States may make program changes but must submit a plan amendment within 30 days of the program changes. The program instruction recommends that the State seek guidance from ACF on whether a particular action is allowable under program requirements. Effect Failure to follow the established procedures in place over the eligibility determination process and to submit a plan amendment or to seek guidance from ACF on whether a particular action is allowable under program requirements, resulted in noncompliance with the requirement and questioned costs. Cause and View of Responsible Officials The Department has a history of backlogged cases, which does not allow them to work on current issue when they arise. Recommendation We recommend that the Department work with ACF to determine what remediation actions, if any, are required.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action, however, notes the following: Letter dated April 29, 2022 was sent to ACF notifying of the temporary amendment to the Hawaii TANF State Plan, Part B, Section 10.1, suspending the interview requirement for TANF applications and annual recertification. The temporary suspension of the interview requirement aligned with the waiver granted by the Food and Nutrition Service for the Supplemental Nutrition Assistance Program (“SNAP”). The letter also informed ACF the interview requirement will resume for new TANF applications by July 31, 2022. No date was provided as to when the interview requirement will resume for annual recertifications. The Department received a letter dated May 9, 2022 from ACF that acknowledged the temporary amendment to the Hawaii TANF State Plan. A subsequent letter dated March 16, 2023 was sent to inform ACF that the suspended interview resumed for TANF applications effective July 1, 2022, however, will continue to be suspended for annual eligibility recertifications for TANF recipients. The Department received a letter dated March 29, 2023 from ACF that acknowledged the temporary State Plan amendment. A letter dated July 25, 2023 informed ACF that TANF will continue to align with SNAP and extend its suspended interview requirement for annual recertifications until May 31, 2024. The Department received a letter dated August 3, 2023 from ACF that acknowledged the extended temporary amendment to the State Plan. The Department did not need guidance from ACF on whether a particular action is allowable under program requirements. Pursuant to section 402 of the Social Security Act, ACF has the authority to determine whether a state’s TANF State Plan is complete but does not have the authority to approve or disapprove a plan. ACF acknowledged the temporary amendments made to the Hawaii TANF State Plan and expressed no concerns or determined that the temporary amendments were not allowable. Corrective Action Taken or Planned: No corrective action. The temporary amendment to the Hawaii TANF State Plan will end effective June 1, 2024, as noted in the July 25, 2023 letter to ACF. Expected Completion Date: Not applicable Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator
2022-011
Finding No. 2023 017: Cash Management (Significant Deficiency) Questioned costs: $ 122,940 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.667 – Social Services Block Grant Award Number and Award Year: 2101HISOSR 2020-25022 2201HISOSR 2021-2023 2301HISOSR 2022 – 2024 Repeat Finding? No Condition During our audit, we selected a non statistical sample of 40 advance payments and for three advance payments we were unable to determine the time elapsed between the drawdown of federal funds and the related disbursement for program purposes. Criteria Pursuant to 31 CFR 205.33(a), the Department is required to minimize the time between the drawdown of Federal funds and their disbursement for Federal program purposes. Effect Failure to track and match the drawdown of federal funds with the related disbursements for program purposes limits the Department’s ability to demonstrate compliance with the requirement and resulted in questioned costs. Cause and View of Responsible Officials Program management indicated that they were unaware of the cash management requirement. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Finding No. 2023 017: Cash Management (Significant Deficiency) Questioned costs: $ 122,940 Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.667 – Social Services Block Grant Award Number and Award Year: 2101HISOSR 2020-25022 2201HISOSR 2021-2023 2301HISOSR 2022 – 2024 Repeat Finding? No Condition During our audit, we selected a non statistical sample of 40 advance payments and for three advance payments we were unable to determine the time elapsed between the drawdown of federal funds and the related disbursement for program purposes. Criteria Pursuant to 31 CFR 205.33(a), the Department is required to minimize the time between the drawdown of Federal funds and their disbursement for Federal program purposes. Effect Failure to track and match the drawdown of federal funds with the related disbursements for program purposes limits the Department’s ability to demonstrate compliance with the requirement and resulted in questioned costs. Cause and View of Responsible Officials Program management indicated that they were unaware of the cash management requirement. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department’s Fiscal Management Office will update and change their procedure by using the entire prior year payroll allotment first, instead of reclassing expenditures to the current year. This will eliminate the excess cash that was sitting in the account. Expected Completion Date: June 2025 Responding Officials: Daisy L. Hartsfield, Social Services Division, Administrator; Carolina B. Anagaran, Social Services Division, Support Services Office, Administrator; Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator; Rachel Thorburn, Child Welfare Services Program Development Office, Assistant Administrator; and Joey Wong, Fiscal Management Office Accountant
FAC accepted this audit on March 29, 2023 — management decision was due September 29, 2023.
Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $21 million of payments out of a total payment population of $223 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Criteria Pursuant to 42 CFR Part 455, subpart E, the Department?s MED Quest Division is required to screen and enroll providers and obtain certain disclosures in accordance with 42 CFR Part 455, subpart B. Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Pursuant to 42 CFR 455, subpart B, providers are to comply with the requirements of the State Plan, including the disclosure requirement. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $21 million of payments out of a total payment population of $223 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Criteria Pursuant to 42 CFR Part 455, subpart E, the Department?s MED Quest Division is required to screen and enroll providers and obtain certain disclosures in accordance with 42 CFR Part 455, subpart B. Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Pursuant to 42 CFR 455, subpart B, providers are to comply with the requirements of the State Plan, including the disclosure requirement. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Finding No. 2022 002: Special Tests and Provisions (Material Weakness) Federal Agency: Department of Health and Human Services AL Number and Title: 93.777, 93.778, and COVID 19 ? 93.778 ? Medicaid Cluster Award Number and Award Year: 2105HIMAP, 2205HIMAP, 2105HIADM, 2205HIADMN Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $21 million of payments out of a total payment population of $223 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned The conversion to the HOKU online provider enrollment system in 2020, the staffing and workload impacts of the COVID 19 public health emergency and the inability to fill key provider enrollment section positions have combined to tax the ability of the Department to come into compliance with the stated criteria. These factors have created backlogs in the processing turnaround time for new provider enrollment applications that have been submitted by providers and are waiting to be processed by the Department. These factors have also hampered the Department?s efforts to timely outreach with providers who are at/over the five-year revalidation threshold. The Department was able to fill the section administrator over the provider enrollment section in June 2022, and also fill a key contract specialist position in August 2022. The Department entered into a new provider enrollment staff augmentation contract with Maximus effective January 1, 2023, and initial vendor performance has been promising. New provider enrollment processing time has been reduced to no more than ten days for certain provider types, and Maximus is on track to eliminate the existing provider enrollment application backlog by the third quarter of 2023. The Department is expecting these changes to result in full compliance with the stated criteria by the end of 2023. Expected Completion Date December 31, 2023 Responding Officials Jon Fujii, MED Quest Division Health Care Services Branch Administrator
2021-003
Condition During our audit, we noted the Department only partially obtained the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Criteria Pursuant to 42 CFR 438.3(m), the Department must require managed care organizations (?MCO?), prepaid inpatient health plans (?PIHP?), and prepaid ambulatory health plans (?PAHP?) to submit audited financial reports, conducted in accordance with generally accepted accounting principles and generally accepted auditing standards, specific to its Medicaid contract on an annual basis. Pursuant to 42 CFR 438.602(e), the Department must periodically, but no less frequently than once every three years, conduct, or contract for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP, or PAHP. Effect Failure to obtain the necessary financial audit reports represents an instance of noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Show full finding ▾Hide full finding ▴Condition During our audit, we noted the Department only partially obtained the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Criteria Pursuant to 42 CFR 438.3(m), the Department must require managed care organizations (?MCO?), prepaid inpatient health plans (?PIHP?), and prepaid ambulatory health plans (?PAHP?) to submit audited financial reports, conducted in accordance with generally accepted accounting principles and generally accepted auditing standards, specific to its Medicaid contract on an annual basis. Pursuant to 42 CFR 438.602(e), the Department must periodically, but no less frequently than once every three years, conduct, or contract for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP, or PAHP. Effect Failure to obtain the necessary financial audit reports represents an instance of noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Finding No. 2022 003: Special Tests and Provisions (Material Weakness) Federal Agency: Department of Health and Human Services AL Number and Title: 93.777, 93.778, and COVID 19 ? 93.778 ? Medicaid Cluster Award Number and Award Year: 2105HIMAP, 2205HIMAP, 2105HIADM, 2205HIADMN Condition During our audit, we noted the Department only partially obtained the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned The Department has identified a gap in training and education, that caused a failure to enforce the contract requirement for plans to submit audited financial statements pursuant to 42 CFR 438.3(m). Training and education will be scheduled over the next few months. The Department has engaged with a vendor to perform an audit of the managed care organizations? medical loss ratio information pursuant to 42 CFR 438.602(e). This work began on July 1, 2022 and is currently on-going. Expected Completion Date June 30, 2023 Responding Officials Eric Nouchi, MED Quest Division Finance Officer, and Jon Fujii, MED Quest Division Health Care Services Branch Administrator
2021-004
Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $240,000 of payments out of a total payment population of $7.2 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Criteria Pursuant to 42 CFR Part 455, subpart E, the Department?s MED Quest Division is required to screen and enroll providers and obtain certain disclosure in accordance with 42 CFR Part 455, subpart B. Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Pursuant to 42 CFR 455, subpart B, Providers are to comply with the requirements of the State Plan, including the disclosure requirement. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $240,000 of payments out of a total payment population of $7.2 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Criteria Pursuant to 42 CFR Part 455, subpart E, the Department?s MED Quest Division is required to screen and enroll providers and obtain certain disclosure in accordance with 42 CFR Part 455, subpart B. Pursuant to 42 CFR 455.414, the State Medicaid Agency must revalidate the enrollment of all providers regardless of provider type at least every five years. Pursuant to 42 CFR 455, subpart B, Providers are to comply with the requirements of the State Plan, including the disclosure requirement. Effect Failure to follow the established policies and procedures in place over the provider eligibility determination process represents an instance of noncompliance with the requirements of 2 CFR Part 200, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Finding No. 2022 004: Special Tests and Provisions (Material Weakness) Federal Agency: Department of Health and Human Services AL Number and Title: 93.767 ? State Children?s Health Insurance Program Award Number and Award Year: 2105HI5022 Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $240,000 of payments out of a total payment population of $7.2 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned The conversion to the HOKU online provider enrollment system in 2020, the staffing and workload impacts of the COVID 19 public health emergency and the inability to fill key provider enrollment section positions have combined to tax the ability of the Department to come into compliance with the stated criteria. These factors have created backlogs in the processing turnaround time for new provider enrollment applications that have been submitted by providers and are waiting to be processed by the Department. These factors have also hampered the Department?s efforts to timely outreach with providers who are at/over the five-year revalidation threshold. The Department was able to fill the section administrator over the provider enrollment section in June 2022, and also fill a key contract specialist position in August 2022. The Department entered into a new provider enrollment staff augmentation contract with Maximus effective January 1, 2023, and initial vendor performance has been promising. New provider enrollment processing time has been reduced to no more than ten days for certain provider types, and Maximus is on track to eliminate the existing provider enrollment application backlog by the third quarter of 2023. The Department is expecting these changes to result in full compliance with the stated criteria by the end of 2023. Expected Completion Date December 31, 2023 Responding Officials Jon Fujii, MED Quest Division Health Care Services Branch Administrator
2021-006
Condition During our audit, we noted the Department only partially obtained the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Criteria Pursuant to 42 CFR 438.3(m), the Department must require MCOs, PIHPs, and PAHPs to submit audited financial reports, conducted in accordance with generally accepted accounting principles and generally accepted auditing standards, specific to its Medicaid contract on an annual basis. Pursuant to 42 CFR 438.602(e), the Department must periodically, but no less frequently than once every three years, conduct, or contract for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. Effect Failure to obtain the necessary financial audit reports represents an instance of noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Show full finding ▾Hide full finding ▴Condition During our audit, we noted the Department only partially obtained the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Criteria Pursuant to 42 CFR 438.3(m), the Department must require MCOs, PIHPs, and PAHPs to submit audited financial reports, conducted in accordance with generally accepted accounting principles and generally accepted auditing standards, specific to its Medicaid contract on an annual basis. Pursuant to 42 CFR 438.602(e), the Department must periodically, but no less frequently than once every three years, conduct, or contract for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. Effect Failure to obtain the necessary financial audit reports represents an instance of noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials Although the Department has policies and procedures in place requiring the maintenance of required documentation, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements.
Finding No. 2022 005: Special Tests and Provisions (Material Weakness) Federal Agency: Department of Health and Human Services AL Number and Title: 93.767 ? State Children?s Health Insurance Program Award Number and Award Year: 2105HI5022 Condition During our audit, we noted the Department only partially obtained the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned The Department has identified a gap in training and education, that caused a failure to enforce the contract requirements for plans to submit audited financial statements pursuant to 42 CFR 438.3(m). Training and education will be scheduled over the next few months. The Department has engaged with a vendor to perform an audit of the managed care organizations? medical loss ratio information pursuant to 42 CFR 438.602(e). This work began on July 1, 2022, and is currently on-going. Expected Completion Date June 30, 2023 Responding Officials Eric Nouchi, MED Quest Division Finance Officer, and Jon Fujii, MED Quest Division Health Care Services Branch Administrator
2021-007
Condition During our audit, we selected a non statistical sample of 60 daily reconciliations for testing and noted 18 instances where variances were not investigated and there was no evidence that a review of the daily reconciliations was performed. The Department?s daily reconciliations identified variances which ranged up to approximately $9.6 million. Criteria Pursuant to 7 CFR 274.4, the Department is required to perform daily reconciliations of all SNAP transactions between the State?s Benefit Account, the US Treasury Department, and all the EBT contractors. Effect Failure to resolve the reconciling items resulted in non-compliance with the requirement. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliations are reviewed in a timely manner.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non statistical sample of 60 daily reconciliations for testing and noted 18 instances where variances were not investigated and there was no evidence that a review of the daily reconciliations was performed. The Department?s daily reconciliations identified variances which ranged up to approximately $9.6 million. Criteria Pursuant to 7 CFR 274.4, the Department is required to perform daily reconciliations of all SNAP transactions between the State?s Benefit Account, the US Treasury Department, and all the EBT contractors. Effect Failure to resolve the reconciling items resulted in non-compliance with the requirement. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliations are reviewed in a timely manner.
Finding No. 2022 006: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 ? 10.561 ? Supplemental Nutrition and Assistance (?SNAP?) Cluster Award Number and Award Year: 7HI4004HI, 7HI400HI4, 7HI430HI4, 7HI400HI5, 7HI430HI5, 7HI460HI6, 227HIHI7F1003 Condition During our audit, we selected a non statistical sample of 60 daily reconciliations for testing and noted 18 instances where variances were not investigated and there was no evidence that a review of the daily reconciliations was performed. The Department?s daily reconciliations identified variances which ranged up to approximately $9.6 million. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned FMO is in the process of creating new reports to identify the daily variances. Once these reports are created, we will be able to reconcile the EBT account daily. As of now, the reports we have do not provide the necessary information to identify these variances. FMO will also create written procedures on how to reconcile the EBT account. Expected Completion Date June 30, 2023 Responding Official Joey Wong, Fiscal Management Office Accountant
2021-010
Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $50,000 in monthly payments, out of a population of approximately 195,000 participant files which approximated $986 million in total annual benefit payments, for testing and noted exceptions in three case files as follows: ? One case file where manually entered unearned income and medical expense deduction amounts did not agree with the documentation retained in the participant?s case file. ? Two case files where manually entered income information did not agree with the documentation retained in the respective participant?s case files. Criteria Pursuant to 7 CFR 272.10(b)(1)(i), the SNAP system should be efficiently automated to determine eligibility and calculate benefits or validate the eligibility worker?s calculations by processing and storing all case file information necessary for the eligibility determination and benefit computation (including but not limited to all household members? names, addresses, dates of birth, social security numbers, individual household members? earned and unearned income by source, deductions, resources, and household size). Effect Participants did not receive the correct amount of benefits they were eligible for, resulting in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant?s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $50,000 in monthly payments, out of a population of approximately 195,000 participant files which approximated $986 million in total annual benefit payments, for testing and noted exceptions in three case files as follows: ? One case file where manually entered unearned income and medical expense deduction amounts did not agree with the documentation retained in the participant?s case file. ? Two case files where manually entered income information did not agree with the documentation retained in the respective participant?s case files. Criteria Pursuant to 7 CFR 272.10(b)(1)(i), the SNAP system should be efficiently automated to determine eligibility and calculate benefits or validate the eligibility worker?s calculations by processing and storing all case file information necessary for the eligibility determination and benefit computation (including but not limited to all household members? names, addresses, dates of birth, social security numbers, individual household members? earned and unearned income by source, deductions, resources, and household size). Effect Participants did not receive the correct amount of benefits they were eligible for, resulting in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant?s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually.
Finding No. 2022 007: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 ? 10.561 ? Supplemental Nutrition and Assistance (?SNAP?) Cluster Award Number and Award Year: 7HI4004HI, 7HI400HI4, 7HI430HI4, 7HI400HI5, 7HI430HI5, 7HI460HI6, 227HIHI7F1003 Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $50,000 in monthly payments, out of a population of approximately 195,000 participant files which approximated $986 million in total annual benefit payments, for testing and noted exceptions in three case files as follows: ? One case file where manually entered unearned income and medical expense deduction amounts did not agree with the documentation retained in the participant?s case file. ? Two case files where manually entered income information did not agree with the documentation retained in the respective participant?s case files. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: Remind eligibility staff to ensure that verification submitted by the household and filed in household?s electronic case folder (ECF) along with documentation on cases through DHS 1006 and/or case notes are consistent with what is processed and recorded in the eligibility system - HAWI, and that processing is completed according to Supplemental Nutrition and Assistance Program (SNAP) policy to ensure that households are receiving the maximum amount of benefits they are eligible to receive. The SNAP office would also coordinate with the Staff Development Office to put an extra emphasis on this area when conducting SNAP basic training for new eligibility workers. Expected Completion Date: September 30, 2023 Responding Official: Manuel Banasihan, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator
2021-017
Condition We selected a non statistical sample of 60 case files which approximated $33,000 in monthly benefit payments, out of a population of approximately 2,500 case files which approximated $15.4 million in total annual benefit payments, for testing and noted exceptions in 38 case files as follows: ? 19 case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. ? 21 case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. ? Eight case files where the ?difficulty of care? determination was missing and therefore did not have any support for the assistance amount paid. ? Eight case files where documentation of a child?s special needs was missing. ? Eight case files where the supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents was missing. ? One case file where documentation of monthly non-recurring expenses was missing. ? One case file where documentation regarding continuation of monthly subsidy payments after the child?s 18th birthday was missing. ? One case file where the final approval was granted to a household with an individual who was convicted of spousal abuse. ? Five case files where the adoption decree was missing from the case records. Criteria Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 671(a)(20)(B), the State shall check any child abuse and neglect registry maintained by the State for information on any prospective foster or adoptive parent and on any other adult living in the home of such a prospective parent. Pursuant to 42 USC 673(a)(2)(A), the State must determine the child to have special needs to be eligible for adoption assistance payments. Pursuant to 42 USC 673(c)(1), the State must determine whether the child cannot or should not be returned to the home of his or her parents. Pursuant to 45 CFR 1356.41(a), the amount of the payment made for nonrecurring expenses of adoption shall be determined though the agreement between the adopting parent(s) and the title IV E agency administering the program. The agreement must indicate the nature and amount of the nonrecurring expenses to be paid. Pursuant to 42 USC 673(a)(4)(A), a payment may not be made to a child who has attained 18 years of age, unless the individual is determined to be one with special needs. Pursuant to 42 USC 671(a)(20)(A)(i), in any case involving a child on whose behalf such payments are to be so made in which a record check reveals a felony conviction for spousal abuse, such final approval shall not be granted. Pursuant to 42 USC 675(3), the agreement for the adoption subsidy must be signed before the final decree of adoption and contains information concerning the nature of services. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents an instance of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non statistical sample of 60 case files which approximated $33,000 in monthly benefit payments, out of a population of approximately 2,500 case files which approximated $15.4 million in total annual benefit payments, for testing and noted exceptions in 38 case files as follows: ? 19 case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. ? 21 case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. ? Eight case files where the ?difficulty of care? determination was missing and therefore did not have any support for the assistance amount paid. ? Eight case files where documentation of a child?s special needs was missing. ? Eight case files where the supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents was missing. ? One case file where documentation of monthly non-recurring expenses was missing. ? One case file where documentation regarding continuation of monthly subsidy payments after the child?s 18th birthday was missing. ? One case file where the final approval was granted to a household with an individual who was convicted of spousal abuse. ? Five case files where the adoption decree was missing from the case records. Criteria Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 671(a)(20)(B), the State shall check any child abuse and neglect registry maintained by the State for information on any prospective foster or adoptive parent and on any other adult living in the home of such a prospective parent. Pursuant to 42 USC 673(a)(2)(A), the State must determine the child to have special needs to be eligible for adoption assistance payments. Pursuant to 42 USC 673(c)(1), the State must determine whether the child cannot or should not be returned to the home of his or her parents. Pursuant to 45 CFR 1356.41(a), the amount of the payment made for nonrecurring expenses of adoption shall be determined though the agreement between the adopting parent(s) and the title IV E agency administering the program. The agreement must indicate the nature and amount of the nonrecurring expenses to be paid. Pursuant to 42 USC 673(a)(4)(A), a payment may not be made to a child who has attained 18 years of age, unless the individual is determined to be one with special needs. Pursuant to 42 USC 671(a)(20)(A)(i), in any case involving a child on whose behalf such payments are to be so made in which a record check reveals a felony conviction for spousal abuse, such final approval shall not be granted. Pursuant to 42 USC 675(3), the agreement for the adoption subsidy must be signed before the final decree of adoption and contains information concerning the nature of services. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents an instance of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Finding No. 2022 008: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.659 and COVID 19 ? 93.659 ? Adoption Assistance Award Number and Award Year: 2101HIADPT, 2201HIADPT Condition We selected a non statistical sample of 60 case files which approximated $33,000 in monthly benefit payments, out of a population of approximately 2,500 case files which approximated $15.4 million in total annual benefit payments, for testing and noted exceptions in 38 case files as follows: ? 19 case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. ? 21 case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. ? Eight case files where the ?difficulty of care? determination was missing and therefore did not have any support for the assistance amount paid. ? Eight case files where documentation of a child?s special needs was missing. ? Eight case files where the supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents was missing. ? One case file where documentation of monthly non-recurring expenses was missing. ? One case file where documentation regarding continuation of monthly subsidy payments after the child?s 18th birthday was missing. ? One case file where the final approval was granted to a household with an individual who was convicted of spousal abuse. ? Five case files where the adoption decree was missing from the case records. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (CWS) will make a note in each specific case record identified in this audit explaining the audit findings, and ? secure current modified adoption agreements for the nineteen missing documents, ? locate missing clearances for the twenty-one cases or re-run them if not located, Note: Not all clearances are secured prior to placement; Federal Bureau of Investigations (FBI) clearances come later and are NOT required prior to placement in a ?provisionally licensed? home. ? document the need precipitating Difficulty of Care (DOC) determination for the 8 records, showing how DOC was calculated. i. ensure that the written Adoption Assistance Agreement (AAA) matches the calculations and amount in the payment system or update/modify the AAA as appropriate, ? secure documentation of child?s special needs for the eight cases, noting categorical eligibility qualification as special needs for children adopted from foster care. Note: Hawaii is in the process of developing its new Comprehensive Child Welfare Information System (CCWIS) and plans to use this system to automatically code children in foster care as meeting the eligibility criteria for special needs. ? secure a copy of the court order which specified that the child should not be returned home, i.e., the order containing the ?contrary to the child?s welfare? language for the eight cases, ? document monthly non-recurring expenses in the missing case, ? document the reason for continuation of monthly subsidy payments after the child?s eighteenth birthday in one case, ? research/review and document why final approval was granted to a household with an individual who was convicted of spousal abuse. i. If review determines that AAA was inappropriately authorized, provide family with an adverse action notice discontinuing the AA and explaining the appeals process, ? Although adoption assistance is an incentive program with payment beginning prior to the finalization of an adoption, secure a copy of the five missing adoption decrees. Note: The adoption decree is NOT required for payment as the AAA must be entered prior to the finalization of an adoption. 2. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within ninety days to ensure missing documentation has been secured and/or properly noted in record. ? Additionally, the MICU will complete a random AA audit review approximately six months later. i. MICU will share random audit findings with CWS Administrators. ii. CWS Administrators will take corrective action based on MICU audit findings. 3. CWS supervisors and Social Services Division (SSD) Staff Development Specialists will ensure that line staff are familiar with these policies and procedures through individual supervision meetings and work product review. ? Staff with errors identified in this audit, consistent errors identified during individual supervision meetings or through work product review will: i. be given coaching/supervisory support to correctly complete documentation, ii. be required to participate in refresher training on Title IV-E Foster Custody, which is offered three times a year with participation documented by Staff Development Office. iii. During this review between the supervisor and the staff, documentation in the case file, as well as Child Protective Services System (CPSS) coding and payments, will be examined for completeness and consistency. iv. Needed corrections will be made to the documents and/or CPSS, as identified in the monthly reviews. 4. In consultation with the Department of Accounting and General Services (DAGS), CWS will develop and implement a new AAA form which identifies payment amounts by age, informing families of the progression. This will eliminate the need for a new agreement when a child moves from one payment category to another, as they age. ? Should the standard AA amounts change, an addendum to this universal agreement will be sent to families noting the change(s). ? Once a new AAA form has been created, the Staff Development Office will update the AA training module to include this new form and offer the updated training in the regular training rotation. 5. At the next Management Leadership Team meeting, CWS Branch Administrators will share with staff the results of this audit, explaining the direct correlation between documentation (or lack thereof) and financial penalties to the State. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in one through five may be modified, based on input from CWS Administrators and/or focus/exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2023 Responding Officials: Kisha C. Raby, Social Services Division Program Development Administrator, Elladine Olevao, Social Services Division Child Welfare Social Services Manager, and Carolina Anagaran, Social Services Division Administrative Officer
2021-011
Condition We selected a non statistical sample of 60 case files which approximated $55,000 in monthly benefit payments, out of a population of approximately 380 case files which approximated $3.9 million in total annual benefit payments, for testing and noted exceptions in 17 case files as follows: ? Seven case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. ? Four case files where the ?difficulty of care? determination was missing and therefore did not have any support for the assistance amount paid. ? One case file where we were unable to determine if a child who attained the age of 14 was consulted regarding the kinship guardianship agreement. ? Three case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing in the case files. ? Two case files where documentation regarding continuation of monthly subsidy payments after the child?s 18th birthday was missing. ? One case file where the supporting documentation regarding whether the State determined that the guardian/permanent custodian has a strong commitment to caring permanently for the child was missing. Criteria Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The "Guardianship/Permanency Assistance Agreement? (Agreement) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department and includes the total amount of assistance payments. The Agreement may be further supplemented due to difficulties in caring for a child as determined by a caseworker on an as needed basis and documented on the ?Difficulty of Care? (DOC) worksheet. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 673(d)(3)(A), a child is eligible when the state agency determines the following: a) With respect to a child who has attained 14 years of age, the child has been consulted regarding the kinship guardianship arrangement. b) Eligible for foster care maintenance payments under 42 USC 672 while residing for at least six consecutive months in the home of the prospective relative guardian. c) Removed from his or her home pursuant to a voluntary placement agreement or as a result of a judicial determination to the effect that continuation in the home would be contrary to the welfare of the child. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Pursuant to 42 USC 671(a)(20)(c), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Pursuant to 42 USC 673(d)(3)(A)(iii), the Title IV-E agency must determine that the child demonstrates a strong attachment to the prospective relative guardian and the relative guardian has a strong commitment to caring permanently for the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents an instance of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non statistical sample of 60 case files which approximated $55,000 in monthly benefit payments, out of a population of approximately 380 case files which approximated $3.9 million in total annual benefit payments, for testing and noted exceptions in 17 case files as follows: ? Seven case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. ? Four case files where the ?difficulty of care? determination was missing and therefore did not have any support for the assistance amount paid. ? One case file where we were unable to determine if a child who attained the age of 14 was consulted regarding the kinship guardianship agreement. ? Three case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing in the case files. ? Two case files where documentation regarding continuation of monthly subsidy payments after the child?s 18th birthday was missing. ? One case file where the supporting documentation regarding whether the State determined that the guardian/permanent custodian has a strong commitment to caring permanently for the child was missing. Criteria Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The "Guardianship/Permanency Assistance Agreement? (Agreement) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department and includes the total amount of assistance payments. The Agreement may be further supplemented due to difficulties in caring for a child as determined by a caseworker on an as needed basis and documented on the ?Difficulty of Care? (DOC) worksheet. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 673(d)(3)(A), a child is eligible when the state agency determines the following: a) With respect to a child who has attained 14 years of age, the child has been consulted regarding the kinship guardianship arrangement. b) Eligible for foster care maintenance payments under 42 USC 672 while residing for at least six consecutive months in the home of the prospective relative guardian. c) Removed from his or her home pursuant to a voluntary placement agreement or as a result of a judicial determination to the effect that continuation in the home would be contrary to the welfare of the child. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Pursuant to 42 USC 671(a)(20)(c), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Pursuant to 42 USC 673(d)(3)(A)(iii), the Title IV-E agency must determine that the child demonstrates a strong attachment to the prospective relative guardian and the relative guardian has a strong commitment to caring permanently for the child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represents an instance of noncompliance with the requirements specified above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Finding No. 2022 009: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.090 and COVID 19 ? 93.090 ? Guardianship Assistance Award Number and Award Year: 2101HIGARD, 2201HIGARD Condition We selected a non statistical sample of 60 case files which approximated $55,000 in monthly benefit payments, out of a population of approximately 380 case files which approximated $3.9 million in total annual benefit payments, for testing and noted exceptions in 17 case files as follows: ? Seven case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. ? Four case files where the ?difficulty of care? determination was missing and therefore did not have any support for the assistance amount paid. ? One case file where we were unable to determine if a child who attained the age of 14 was consulted regarding the kinship guardianship agreement. ? Three case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing in the case files. ? Two case files where documentation regarding continuation of monthly subsidy payments after the child?s 18th birthday was missing. ? One case file where the supporting documentation regarding whether the State determined that the guardian/permanent custodian has a strong commitment to caring permanently for the child was missing. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (CWS) will make a note in each specific case record identified in this audit explaining the audit findings, and secure missing/incomplete eligibility documents for cases identified in the audit. 2. The identified errors and the related corrective action step above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within ninety days to ensure missing documentation has been secured and properly noted in record. ? Additionally, the MICU will complete a random Guardianship Agreement audit review approximately six months later. i. MICU will share random audit findings with CWS Administration. ii. CWS Administrators will take corrective action based on MICU audit findings. 3. CWS supervisors will ensure that line staff are familiar with these policies and procedures and monitor through individual supervision meetings and work product review. ? Staff with errors identified in this audit, during individual supervision meetings or through work product review will: i. Be given coaching/supervisory support to correctly complete documentation. ii. Be required to participate in refresher training on Title IV-E Foster Custody, which is offered three times a year with participation documented by Staff Development Office. ? All staff who manage payment-only cases will review a quarter of their cases each month with their supervisor, during monthly supervision. i. Each month a different quarter of their cases will be reviewed, so that all cases are reviewed three times a year. ii. During this review between the supervisor and the staff, documentation in the case file, as well as Child Protective Services System (CPSS) coding and payments, will be examined for completeness and accuracy. iii. Needed corrections will be made to the documents and/or CPSS, as identified in the monthly reviews. iv. If a supervisor notices consistent errors by a staff member in Guardianship Agreement documentation, they shall refer the staff to the Staff Development Office for refresher training. v. The supervisor shall document which cases were reviewed each month. 4. At the next Management Leadership Team meeting, CWS Branch Administrators will share with staff the results of this audit, explaining the direct correlation between documentation (or lack thereof) and financial penalties to the State. ? Reminder conversation about this audit and the importance of following current policies and procedures will be held during CWS weekly huddles. 5. As CWS implements this corrective action plan and monitors the results, the action steps proposed in one through four may be modified based on input from CWS Administrators and/or focus/exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2023 Responding Officials: Kisha C. Raby, Social Services Division Program Development Administrator, Elladine Olevao, Social Services Division Child Welfare Social Services Manager, and Carolina Anagaran, Social Services Division Administrative Officer
2021-012
Condition We selected a non statistical sample of 60 case files for testing and noted 11 instances where the Department?s records did not support the use of the income information obtained through Income Eligibility and Verification System (?IEVS?) to evaluate or re-evaluate the benefit calculation. Criteria Pursuant to 45 CFR 205.55, the Department is required to request through the IEVS, wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Effect Failure to properly use IEVS information to evaluate benefit amounts resulted in potential over payment of benefits. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non statistical sample of 60 case files for testing and noted 11 instances where the Department?s records did not support the use of the income information obtained through Income Eligibility and Verification System (?IEVS?) to evaluate or re-evaluate the benefit calculation. Criteria Pursuant to 45 CFR 205.55, the Department is required to request through the IEVS, wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Effect Failure to properly use IEVS information to evaluate benefit amounts resulted in potential over payment of benefits. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Finding No. 2022 010: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition We selected a non statistical sample of 60 case files for testing and noted 11 instances where the Department?s records did not support the use of the income information obtained through Income Eligibility and Verification System (?IEVS?) to evaluate or re-evaluate the benefit calculation. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: It was noted in the Corrective Action Plan, in response to the State fiscal year 2021 audit finding, the DHS 1006 form, ?Eligibility Documentation? (formerly titled ?Interview Documentation?), was revised to require the eligibility of staff to notate the date the Income Eligibility and Verification System (IEVS) query was completed, the findings, and what information was used for eligibility determinations. However, for most of the State fiscal year 2022, the interview requirement for new applicants and annual recertifications for recipients were waived; therefore, the DHS 1006 form was not utilized. Form DHS 1006 will be revised further to create IEVS query fields specifically under Section IX ? Temporary Assistance for Needy Families (TANF) Requirements, and a policy clarification will be issued to remind staff of the IEVS query requirement and instructions on how to complete the DHS 1006 form. Expected Completion Date: September 30, 2023 Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2021-013
Condition We selected a non statistical sample of 60 participant files, representing approximately $39,000 of benefit payments, out of a population of approximately 8,700 cases, representing approximately $17.8 million of benefit payments, for testing and noted exceptions in 17 case files as follows: ? Nine case files where eligibility redeterminations were not completed in the timeframe required by the State Plan. ? Seven case files where there was no evidence of a TANF case worker?s signature on the eligibility redetermination form. ? One case file where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. Criteria The State of Hawaii Temporary Assistance for Needy Families (?TANF?) State Plan states that a review of all eligibility requirements is required every 12 months for all TANF households. The State Plan also states that for the Department to make a decision regarding an applicant?s eligibility, an interview must be conducted with the applicant no later than forty-five (45) days after the application is received. In addition, Administration for Children and Families (?ACF?) program instruction TANF-ACF-PI-2020-01 indicates that States may make program changes but must submit a plan amendment within 30 days of the program changes. The program instruction recommends that the State seek guidance from ACF on whether a particular action is allowable under program requirements. Effect Failure to follow the established procedures in place over the eligibility determination process and to submit the plan amendment or to seek guidance from ACF on whether a particular action is allowable under program requirements, resulted in non-compliance with the requirement and questioned costs. Cause and View of Responsible Officials Due to the COVID 19 pandemic, the Department elected to suspend all eligibility redeterminations until July 2021 and the interview process until July 2022. Although program changes are allowed, the Department was not able to submit the amendment to the State Plan until April 2022. Recommendation We recommend that the Department work with ACF to determine what remediation actions, if any, are required.
Show full finding ▾Hide full finding ▴Condition We selected a non statistical sample of 60 participant files, representing approximately $39,000 of benefit payments, out of a population of approximately 8,700 cases, representing approximately $17.8 million of benefit payments, for testing and noted exceptions in 17 case files as follows: ? Nine case files where eligibility redeterminations were not completed in the timeframe required by the State Plan. ? Seven case files where there was no evidence of a TANF case worker?s signature on the eligibility redetermination form. ? One case file where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. Criteria The State of Hawaii Temporary Assistance for Needy Families (?TANF?) State Plan states that a review of all eligibility requirements is required every 12 months for all TANF households. The State Plan also states that for the Department to make a decision regarding an applicant?s eligibility, an interview must be conducted with the applicant no later than forty-five (45) days after the application is received. In addition, Administration for Children and Families (?ACF?) program instruction TANF-ACF-PI-2020-01 indicates that States may make program changes but must submit a plan amendment within 30 days of the program changes. The program instruction recommends that the State seek guidance from ACF on whether a particular action is allowable under program requirements. Effect Failure to follow the established procedures in place over the eligibility determination process and to submit the plan amendment or to seek guidance from ACF on whether a particular action is allowable under program requirements, resulted in non-compliance with the requirement and questioned costs. Cause and View of Responsible Officials Due to the COVID 19 pandemic, the Department elected to suspend all eligibility redeterminations until July 2021 and the interview process until July 2022. Although program changes are allowed, the Department was not able to submit the amendment to the State Plan until April 2022. Recommendation We recommend that the Department work with ACF to determine what remediation actions, if any, are required.
Finding No. 2022 011: Eligibility (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition We selected a non statistical sample of 60 participant files, representing approximately $39,000 of benefit payments, out of a population of approximately 8,700 cases, representing approximately $17.8 million of benefit payments, for testing and noted exceptions in 17 case files as follows: ? Nine case files where eligibility redeterminations were not completed in the timeframe required by the State Plan. ? Seven case files where there was no evidence of a TANF case worker?s signature on the eligibility redetermination form. ? One case file where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Administration for Children and Families (?ACF?) will be notified in writing, within the required timeframe, if additional amendments will be or are made to the current Temporary Assistance for Needy Families State Plan. Expected Completion Date: On-going Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2021-014
Condition We selected a non statistical sample of 14 participant files for testing out of a population of 138 participant files that were initially determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. We noted 3 files did not contain any correspondence, notices, or documentation to indicate whether any follow up action, up to and including case closure and cessation of benefits, were performed. Criteria Pursuant to 45 CFR 264.30, the Title IV A agency is required to take appropriate action, as defined, if the Title IV D agency determines that an individual is not cooperating with the child support enforcement requirements. Effect Failure to retain documentation to support a determination that appropriate action was taken limits the Department?s ability to demonstrate compliance with the requirement and resulted in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non statistical sample of 14 participant files for testing out of a population of 138 participant files that were initially determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. We noted 3 files did not contain any correspondence, notices, or documentation to indicate whether any follow up action, up to and including case closure and cessation of benefits, were performed. Criteria Pursuant to 45 CFR 264.30, the Title IV A agency is required to take appropriate action, as defined, if the Title IV D agency determines that an individual is not cooperating with the child support enforcement requirements. Effect Failure to retain documentation to support a determination that appropriate action was taken limits the Department?s ability to demonstrate compliance with the requirement and resulted in questioned costs. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Finding No. 2022 012: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition We selected a non statistical sample of 14 participant files for testing out of a population of 138 participant files that were initially determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. We noted 3 files did not contain any correspondence, notices, or documentation to indicate whether any follow up action, up to and including case closure and cessation of benefits, were performed. Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, notes the following: Based on my review of the selected cases, particularly the cases that were properly closed due to non-compliance with child support requirements, I found that the Processing Centers received hard-copy notifications from the Child Support Enforcement Agency (?CSEA?). The three cases indicated as having no closure notices, there were no hard-copy notifications found in the clients? electronic case files. The referrals to CSEA are done through an interface between the HAWI and CSEA's KEIKI systems. When a recipient is determined non-compliant by CSEA, the information is sent via the interface from KEIKI to HAWI in the form of a system-generated alert. This process worked well when application processing and maintenance of recipient cases were done in a case management method (e.g., each eligibility worker assigned to process applications and/or maintain a caseload of active cases). This method, eligibility workers would manage their caseloads and check for incoming alerts for cases assigned to them; these alerts would include the CSEA non-compliant alerts coming from KEIKI system. Workers were able to take appropriate and timely action in response to the alerts received. However, necessary changes were made to how applications and active cases are managed. The division stopped the case management method and converted to "task-oriented" processing statewide. Workers are no longer assigned to caseloads but are assigned to "tasks" such as processing applications, incoming documents/verifications, reported changes, six-month review and annual recertifications, etc. A case is not reviewed and worked in HAWI until a worker is prompted to do so, e.g., six-month review, annual recertification, change was reported by the household, or when a document pertaining to a case is received by the Processing Center such as hard-copy notice sent from CSEA indicating a client did not comply with child support requirements. When any one of these occur, then the worker who is assigned to that task will check for alerts for the case. Aside from that, recipient cases are not reviewed. So how the "alerts" were developed in HAWI no longer works for the way we currently process applications and maintain cases. We are unable to modify the HAWI system because we are currently developing a new eligibility system that will replace HAWI. Corrective Action Taken or Planned: We created an ad hoc report to identify Temporary Assistance for Needy Families Program (TANF) recipient cases that received the HAWI alert, ?REASON [Numeric Code]: CLIENT FAILED TO COOPERATE W/CSEU ON [mmddyyyy]?, generated by the interface with the KEIKI system. The report identifies cases by Case Number, Case Name, and assigned Processing Center. The program office will disseminate the list to the Processing Centers to take appropriate and timely action. The ad hoc report will be requested from the Department?s Office of Information and Technology (?OIT?) and disseminated monthly. Expected Completion Date: On-going Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2021-015
Condition During our audit, we tested a non statistical sample of six subawards and found no evidence that the reporting required by Section 2, Full Disclosure of Entities Receiving Federal Funding, of the Federal Funding Accountability and Transparency Act (?FFATA?) was completed for one subaward and five instances of untimely submission. Criteria Section 2, Full Disclosure of Entities Receiving Federal Funding, of the FFATA requires an entity to report subcontracts made under federally-awarded contracts by the end of the month following the month in which the prime recipient awards any subgrant greater than or equal to $30,000. Effect Failure to file required reports reduced transparency on the use of program funds and represents an instance of noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all award requirements, and that program personnel ensure that required FFATA reports are filed timely.
Show full finding ▾Hide full finding ▴Condition During our audit, we tested a non statistical sample of six subawards and found no evidence that the reporting required by Section 2, Full Disclosure of Entities Receiving Federal Funding, of the Federal Funding Accountability and Transparency Act (?FFATA?) was completed for one subaward and five instances of untimely submission. Criteria Section 2, Full Disclosure of Entities Receiving Federal Funding, of the FFATA requires an entity to report subcontracts made under federally-awarded contracts by the end of the month following the month in which the prime recipient awards any subgrant greater than or equal to $30,000. Effect Failure to file required reports reduced transparency on the use of program funds and represents an instance of noncompliance with the requirements of 2 CFR Part 200. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all award requirements, and that program personnel ensure that required FFATA reports are filed timely.
Finding No. 2022 013: Reporting (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition During our audit, we tested a non statistical sample of six subawards and found no evidence that the reporting required by Section 2, Full Disclosure of Entities Receiving Federal Funding, of the Federal Funding Accountability and Transparency Act (?FFATA?) was completed for one subaward and five instances of untimely submission. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Federal-funded contracts will be entered into the Federal Funding Accountability and Transparency Act Subaward Reporting System in a timely manner. Expected Completion Date: On-going Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
2021-016
Condition During our audit, we selected a non statistical sample of 60 participants for testing out of a population of approximately 7,900 participants whose work participation activity was reported on the ACF-199. We noted one instance where a work eligible participant complied with their work participation plan, but the Department inaccurately reported the participant as noncompliant. Criteria Pursuant to 45 CFR 265.3(b)(1), on a quarterly basis, the Department is required to submit disaggregated information on families receiving Temporary Assistance for Needy Families benefits, which includes demographic data such as work participation activities. Effect Failure to report accurate work participation information limits the Department?s ability to demonstrate compliance with the requirement and could result in non-compliance with the minimum work participation rate requirements. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non statistical sample of 60 participants for testing out of a population of approximately 7,900 participants whose work participation activity was reported on the ACF-199. We noted one instance where a work eligible participant complied with their work participation plan, but the Department inaccurately reported the participant as noncompliant. Criteria Pursuant to 45 CFR 265.3(b)(1), on a quarterly basis, the Department is required to submit disaggregated information on families receiving Temporary Assistance for Needy Families benefits, which includes demographic data such as work participation activities. Effect Failure to report accurate work participation information limits the Department?s ability to demonstrate compliance with the requirement and could result in non-compliance with the minimum work participation rate requirements. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Finding No. 2022 014: Special Tests and Provisions (Significant Deficiency) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition During our audit, we selected a non statistical sample of 60 participants for testing out of a population of approximately 7,900 participants whose work participation activity was reported on the ACF-199. We noted one instance where a work eligible participant complied with their work participation plan, but the Department inaccurately reported the participant as noncompliant. Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, notes the following: Several jobs are run each month following the report month, to extract client data from the HAWI (eligibility data) and HANA (work participation data) systems to create the ACF-199 Temporary Assistance for Needy Families data reports. Each ACF-199 report is created monthly, then compiled and submitted following the end of each report quarter. If changes are made to any client data in the HAWI or HANA systems after the creation of each report month, the changes will not be captured and will not reflect on the ACF-199 Quarter Reports submitted to the Administration for Children and Families. Corrective Action Taken or Planned: A rerun of the ACF-199 Report will be scheduled every November/December, following the end of each federal fiscal year, to create a final report and submit by the annual reporting deadline of December 31st. This will capture any client data changes made after each report month?s job run. Expected Completion Date: Beginning November/December 2023 (for final FFY 2023 reports) and annually thereafter. Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
Condition We selected a non statistical sample of 40 case files which approximated $32,000 in monthly benefit payments, out of a population of approximately 981 case files which approximated $4.89 million in total annual benefit payments, for testing and noted exceptions in 13 case files as follows: ? Three case files where the Police Protective Custody form or Voluntary Foster Custody Agreement was missing and therefore did not support whether the child was removed as part of a voluntary placement agreement or judicial determination. ? Three case files where the State, FBI, and/or child abuse and neglect clearances were missing. ? Seven case files where the ?difficulty of care? determination was missing and therefore did not support the assistance amount paid. ? Two case files where the ?Certificate of Approval? was missing and therefore did not support whether the prospective foster parents were licensed. Criteria Pursuant to 42 USC 672(a)(2), the State must determine whether the removal and foster care placement of a child was in accordance with a voluntary placement agreement or judicial determination. Pursuant to 42 USC 675(4)(A), the foster care maintenance payments should cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, and a child?s personal incidentals. Pursuant to 42 USC 672(c)(1)(A), a foster family home means the home of an individual family that is licensed or approved by the State in which it is situated as a foster family home that meets the standards established for the licensing or approval. Pursuant to 42 USC 671(a)(20)(A), any prospective foster parent must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases, before the foster parent may be finally approved for placement of a child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represent instances of noncompliance with the requirements above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition We selected a non statistical sample of 40 case files which approximated $32,000 in monthly benefit payments, out of a population of approximately 981 case files which approximated $4.89 million in total annual benefit payments, for testing and noted exceptions in 13 case files as follows: ? Three case files where the Police Protective Custody form or Voluntary Foster Custody Agreement was missing and therefore did not support whether the child was removed as part of a voluntary placement agreement or judicial determination. ? Three case files where the State, FBI, and/or child abuse and neglect clearances were missing. ? Seven case files where the ?difficulty of care? determination was missing and therefore did not support the assistance amount paid. ? Two case files where the ?Certificate of Approval? was missing and therefore did not support whether the prospective foster parents were licensed. Criteria Pursuant to 42 USC 672(a)(2), the State must determine whether the removal and foster care placement of a child was in accordance with a voluntary placement agreement or judicial determination. Pursuant to 42 USC 675(4)(A), the foster care maintenance payments should cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, and a child?s personal incidentals. Pursuant to 42 USC 672(c)(1)(A), a foster family home means the home of an individual family that is licensed or approved by the State in which it is situated as a foster family home that meets the standards established for the licensing or approval. Pursuant to 42 USC 671(a)(20)(A), any prospective foster parent must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases, before the foster parent may be finally approved for placement of a child. Effect Failure to follow the established policies and procedures in place over the application process and determination of assistance amount represent instances of noncompliance with the requirements above, resulting in questioned costs. Cause and View of Responsible Officials Although the Department has established policies and procedures in place regarding the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including those specified under Criteria above. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Finding No. 2022 015: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.658 and COVID 19 ? 93.658 ? Foster Care ? Title IV E Award Number and Award Year: 2101HIFOST, 2201HIFOST Condition We selected a non statistical sample of 40 case files which approximated $32,000 in monthly benefit payments, out of a population of approximately 981 case files which approximated $4.89 million in total annual benefit payments, for testing and noted exceptions in 13 case files as follows: ? Three case files where the Police Protective Custody form or Voluntary Foster Custody Agreement was missing and therefore did not support whether the child was removed as part of a voluntary placement agreement or judicial determination. ? Three case files where the State, FBI, and/or child abuse and neglect clearances were missing. ? Seven case files where the ?difficulty of care? determination was missing and therefore did not support the assistance amount paid. ? Two case files where the ?Certificate of Approval? was missing and therefore did not support whether the prospective foster parents were licensed. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (CWS) will make a note in each specific case record identified in this audit explaining the audit findings, and secure missing/incomplete eligibility documents for cases identified in the audit. 2. The identified errors and the related corrective action step above will be reviewed by CWS Administrators, staff supervisors, and Management Information Compliance Unit (MICU) within ninety days to ensure missing documentation has been secured and properly noted in record. ? Additionally, the MICU will complete a random Title IV-E Foster Custody payments audit review approximately six months later. i. MICU will share random audit findings with CWS Administrators. ii. CWS Administrators will take corrective action based on MICU audit findings. 3. CWS supervisors will ensure that line staff (especially those responsible for Licensing and Placements) are familiar with these policies and procedures and monitor through individual supervision meetings and work product review. ? Staff with errors identified in this audit, during individual supervision meetings or through work product review will: i. be given coaching/supervisory support to correctly complete documentation, ii. be required to participate in refresher training on Title IV-E Foster Custody, which is offered three times a year with participation documented by Staff Development Office. ? All staff who manage Title IV-E Foster Custody payments will review a quarter of their cases each month with their supervisor, during monthly supervision. i. Each month, a different quarter of their cases will be reviewed, always starting with the newest cases. ii. During this review between the supervisor and the staff, documentation in the case file, as well as Child Protective Services System (CPSS) coding and payments, will be examined for completeness and consistency. iii. Needed corrections will be made to the documents and/or CPSS, as identified in the monthly reviews. iv. If a supervisor notices consistent errors by a staff member in Title IV-E Foster Custody payments documentation, they shall refer the staff to the Staff Development Office for refresher training. v. The supervisor shall document which cases were reviewed each month. ? All licensing staff shall review a quarter of their cases every month with their supervisor, during monthly supervision. i. Each month, a different quarter of their cases will be reviewed, always starting with the newest cases. ii. During this review between the supervisor and the staff, documentation (including all background clearances) in the case file will be examined for timeliness and completeness. iii. Needed corrections will be made to the documents and/or new documents added, as identified in the monthly reviews. iv. If a supervisor notices consistent errors by a staff member in Title IV-E Foster Custody payments documentation, they shall refer the staff to the Staff Development Office for refresher training. v. The supervisor shall document which cases were reviewed each month. 4. At the next Management Leadership Team meeting, CWS Branch Administrators will share with staff the results of this audit, explaining the direct correlation between documentation (or lack thereof) and financial penalties to the State. ? Reminder conversations about this audit and the importance of following current policies and procedures will be held during CWS weekly huddles. 5. As CWS implements this corrective action plan and monitors the results, the action steps proposed in one through four may be modified based on input from CWS Administrators and/or focus/exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2023, and On-going Responding Officials: Kisha C. Raby, Social Services Division Program Development Administrator, Elladine Olevao, Social Services Division Child Welfare Social Services Manager, and Carolina Anagaran, Social Services Division Administrative Officer
Condition The Department achieved a two-parent work participation rate of 12.4%, which is below the federally mandated rate of 15.7%, calculated by subtracting the caseload reduction credit of 74.3% from the base 90.0%. Criteria Pursuant to 45 CFR 261.23, a State must achieve a 90% minimum two-parent participation rate minus any caseload reduction credit to which it is entitled. Pursuant to 45 CFR 261.40(a)(2)(i), the minimum two-parent participation rate the State must meet decreases by the number of percentage points the prior-year two-parent caseload, including two-parent cases receiving assistance under a separate State program, fell in comparison to the FY 2005 two-parent caseload, including two-parent cases receiving assistance under a separate State program. Effect Failure to meet the minimum two-parent work participation rate may result in a reduction in the amount of State family assistance grants received. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Show full finding ▾Hide full finding ▴Condition The Department achieved a two-parent work participation rate of 12.4%, which is below the federally mandated rate of 15.7%, calculated by subtracting the caseload reduction credit of 74.3% from the base 90.0%. Criteria Pursuant to 45 CFR 261.23, a State must achieve a 90% minimum two-parent participation rate minus any caseload reduction credit to which it is entitled. Pursuant to 45 CFR 261.40(a)(2)(i), the minimum two-parent participation rate the State must meet decreases by the number of percentage points the prior-year two-parent caseload, including two-parent cases receiving assistance under a separate State program, fell in comparison to the FY 2005 two-parent caseload, including two-parent cases receiving assistance under a separate State program. Effect Failure to meet the minimum two-parent work participation rate may result in a reduction in the amount of State family assistance grants received. Cause and View of Responsible Officials There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements. Additionally, we recommend that the Department diligently comply with its policies and procedures.
Finding No. 2022 016: Reporting (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition The Department achieved a two-parent work participation rate of 12.4%, which is below the federally mandated rate of 15.7%, calculated by subtracting the caseload reduction credit of 74.3% from the base 90.0%. Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, notes the following: Pursuant to 45 CFR 262.5, the Department submitted a letter to the Administration for Children and Families (?ACF?), dated November 21, 2022, to request consideration for reasonable cause for not meeting the fiscal year 2021 Two-Parent Work Participation Rate. The ACF confirmed receipt of the Department?s request on November 28, 2022. Determination and decision from ACF are currently pending. Corrective Action Taken or Planned: The work participation requirement under the Upfront Universal Engagement (UFUE), described in sections 17-656.1-8.4 and 17-794.1-36, Hawaii Administrative Rules, were reinstated effective June 2022. Applicants are required to fulfill the work participation requirements described in the rules, as a condition of Temporary Assistance for Needy Families (TANF) eligibility. The upfront work participation provides applicants with job readiness training, new or updated resume, and job search assistance. The upfront participation requirement has shown success in preparing parents/relative caregivers with work program engagement prior to June 2022 and the upfront participation requirements were waived because there was an increased need for financial assistance during the pandemic. In 2022, the TANF program office established quarterly collaborative meetings with the work program unit supervisors statewide. The meetings are structured with specific components: 1. Share information and resources from community-based organizations that service families with dependent children, 2. Provide program updates such as policy changes and projects, 3. Activities that involve collaboration amongst attendees (e.g., discussions on topics relating to TANF recipient families, staff who work directly with families, and program implementation); and 4. Summary of the collaborative activity and next steps. The quarterly meetings provide an avenue for the program office and unit supervisors to discuss challenges that work program staff encounter working with participants; to develop strategies on engaging new participants and re-engaging those who have been in the work program, particularly during this period of transition following the pandemic; and identify any needs that families may have that the work program is unable to provide. The quarterly collaborative meetings will continue in 2023 and will be conducted on an on-going basis. Expected Completion Date: On-going Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
Condition During our audit, we selected a non statistical sample of four processing centers out of the Department?s 21 processing centers and noted that supervisor reviews performed over DHS Form 1494, Form 1495, and/or Form 1050 were not maintained at one processing center. Criteria Pursuant to 7 CFR 274.8(b)(3), the Department is required to ensure there are storage and control measures to control blank unissued electronic benefit transfer (EBT) cards. To address this requirement, the Department has adopted a policy that requires (1) monthly or quarterly review of the DHS Form 1494, Bulk Inventory Control Log; (2) daily or weekly review of the DHS Form 1495, Hawaii EBT Card Daily Control Log; and (3) monthly review of the DHS Form 1050, EBT Card Destruction Control Log. Effect Documentation of supervisor approval of the review over the DHS Form 1494, Form 1495, and/or Form 1050 was not maintained at one processing center, increasing the risk of non-compliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require a supervisor sign-off documenting their review resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department modify their policies and procedures to explicitly require supervisor signoffs documenting their review.
Show full finding ▾Hide full finding ▴Condition During our audit, we selected a non statistical sample of four processing centers out of the Department?s 21 processing centers and noted that supervisor reviews performed over DHS Form 1494, Form 1495, and/or Form 1050 were not maintained at one processing center. Criteria Pursuant to 7 CFR 274.8(b)(3), the Department is required to ensure there are storage and control measures to control blank unissued electronic benefit transfer (EBT) cards. To address this requirement, the Department has adopted a policy that requires (1) monthly or quarterly review of the DHS Form 1494, Bulk Inventory Control Log; (2) daily or weekly review of the DHS Form 1495, Hawaii EBT Card Daily Control Log; and (3) monthly review of the DHS Form 1050, EBT Card Destruction Control Log. Effect Documentation of supervisor approval of the review over the DHS Form 1494, Form 1495, and/or Form 1050 was not maintained at one processing center, increasing the risk of non-compliance with the requirement. Cause and View of Responsible Officials Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require a supervisor sign-off documenting their review resulting in the inconsistent application and documentation of supervisor reviews. Recommendation We recommend that program management ensure that program personnel are familiar with all grant requirements, including compliance with 2 CFR Part 200. Additionally, we recommend that the Department modify their policies and procedures to explicitly require supervisor signoffs documenting their review.
Finding No. 2022 017: Special Tests and Provisions (Significant Deficiency) Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 ? 10.561 ? Supplemental Nutrition and Assistance (?SNAP?) Cluster Award Number and Award Year: 7HI4004HI, 7HI400HI4, 7HI430HI4, 7HI400HI5, 7HI430HI5, 7HI460HI6, 227HIHI7F1003 Condition During our audit, we selected a non statistical sample of four processing centers out of the Department?s 21 processing centers and noted that supervisor reviews performed over DHS Form 1494, Form 1495, and/or Form 1050 were not maintained at one processing center. Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, disagrees with the recommendation in that policies and procedures have already been implemented to require supervisor signoffs documenting their review. Corrective Action Taken or Planned: Forms and instructions for forms DHS 1494, 1495, and 1050 were updated in March 2022 as a recommendation from the last audit to add an additional column on these forms for the Supervisor/Auditor to date and initial the form to indicate an audit took place. Will ensure all staff members are familiar with all grant requirements, including compliance with 2 CFR Part 200. Completion Date: March 2023 Responding Official: Sabrina Young, Benefit, Employment, and Support Services Division Electronic Benefit Transfer Project Manager
2021-018
FAC accepted this audit on March 31, 2022 — management decision was due October 1, 2022.
The Department did not properly credit the CMS-64 report for overpayments discovered. Context: The Department reported and refunded only collected overpayments, however overpayments discovered and not recovered were not reported and refunded. Cause: The Department was initially made aware of the requirements as a result of prior year?s audit, however, policies and procedures were not put in place in time to take corrective action during the entire year. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-003. Recommendations: We recommend the Department establish policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-002 Refunding of Medicaid Overpayments Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Special Tests and Provisions - Refunding of Medicaid Overpayments Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2005HI5MAP 2020 2105HI5MAP 2021 Criteria: The State Medicaid Agency, Department of Human Services, Med Quest Division is required to refund the federal share of Medicaid overpayments made to providers in accordance with 42 U.S.C. 1396b and 42 CFR subpart F. Pursuant to 42 U.S.C. 1396b, the State Medicaid Agency has up to one year from the date of discovery of Medicaid overpayments to recover or attempt to recover the overpayments before the federal share must be refunded, regardless of whether recovery if made from the provider. Pursuant to 42 CFR 433.320(a)(2) the State Medicaid Agency must credit CMS with the Federal share of overpayments subject to recovery on the earlier of (1) the form CMS-64 submission due to CMS for the quarter in which the State recovers the overpayment from the provider; or (2) the form CMS-64 due to CMS for the quarter in which the 1-year period following discovery ends. Condition: The Department did not properly credit the CMS-64 report for overpayments discovered. Context: The Department reported and refunded only collected overpayments, however overpayments discovered and not recovered were not reported and refunded. Cause: The Department was initially made aware of the requirements as a result of prior year?s audit, however, policies and procedures were not put in place in time to take corrective action during the entire year. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-003. Recommendations: We recommend the Department establish policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: A new report template has been created and as of July 1, 2021, the MCOs will report quarterly on all active overpayments (either overpayments identified during the reporting period or identified in previous reporting periods but are still in active recovery). For these overpayments, Health Plans will report on the full amount of overpayment identified as well as the amount they have recovered. The MCOs will also report ad hoc on any overpayments from MQD they?ve identified through capitation (e.g., if they notice they receive capitation for a member who is deceased or who is duplicated). End Date: The Health Plans have already begun to submit this report as of February 2022.
2020-003
14 provider files did not contain the required documentation to support compliance with the provider eligibility requirement. Context: We selected a non-statistical sample of 60 providers for testing out of a population of approximately 5,800 providers. The providers selected for testing represented approximately $36 million of payments out of a total payment population of approximately $119 million. The results of our testing were as follows ? 5 providers where the DHS Form-1139 was not maintained. ? 1 provider where documentation was missing which discloses the agreement of the providers to comply with disclosure requirements. ? 5 providers where the DHS Form-1139 did not support revalidation within the most recent 5-year period. ? 2 providers where the DHS Form-1139 did not support revalidation within the most recent 5-year period and the documentation to indicate whether the required pre-enrollment or post-enrollment on-site inspections were performed. ? 1 provider where the DHS Form-1139 was not maintained and documentation was missing to support the provider type and risk level and therefore we could not determine whether on-site visits were required. Cause: Although the Department has policies and procedures in place requiring the maintenance of required documentation and on-site visits, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement resulting in questioned costs. Questioned costs: $6,973,399 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-004. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-003 Revalidation of Provider Eligibility Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Special Tests and Provisions - Provider Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2005HI5MAP 2020 2105HI5MAP 2021 Criteria: The State Medicaid Agency, Department of Human Services, Med Quest Division is required to screen and enroll providers in accordance with 42 CFR Part 455, subpart E and make certain disclosures to the State Medicaid Agency in accordance with 42 CFR Part 455, subpart B. Pursuant 42 CFR 455.414, the State Medicaid agency must revalidate the enrollment of all providers regardless of provider type at least every 5 years. Pursuant to 42 CFR 455.432, the State Medicaid Agency must (a) conduct pre-enrollment site visits of providers who are designated as ?moderate? or ?high? categorical risks to the Medicaid program and (b) must require any enrolled provider to permit CMS, its agents, its designated contractors, or the State Medicaid Agency to conduct unannounced on-site inspections of any or all provider locations. Pursuant to 42 CFR 455 Subpart B, Providers are to comply with the requirements of the State Plan, including the disclosure requirement. The Department utilizes DHS Form-1139 as the provider application that screens and verifies licensure and enrollment in the program. DHS Form-1139 also documents the provider agreement to disclose information as required. Condition: 14 provider files did not contain the required documentation to support compliance with the provider eligibility requirement. Context: We selected a non-statistical sample of 60 providers for testing out of a population of approximately 5,800 providers. The providers selected for testing represented approximately $36 million of payments out of a total payment population of approximately $119 million. The results of our testing were as follows ? 5 providers where the DHS Form-1139 was not maintained. ? 1 provider where documentation was missing which discloses the agreement of the providers to comply with disclosure requirements. ? 5 providers where the DHS Form-1139 did not support revalidation within the most recent 5-year period. ? 2 providers where the DHS Form-1139 did not support revalidation within the most recent 5-year period and the documentation to indicate whether the required pre-enrollment or post-enrollment on-site inspections were performed. ? 1 provider where the DHS Form-1139 was not maintained and documentation was missing to support the provider type and risk level and therefore we could not determine whether on-site visits were required. Cause: Although the Department has policies and procedures in place requiring the maintenance of required documentation and on-site visits, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement resulting in questioned costs. Questioned costs: $6,973,399 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-004. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: Lack of staffing and a paper intensive process are the root causes of this finding. The State worker hiring freeze caused by the COVID pandemic further exacerbated the staffing issues. To remediate the staffing issue, a vendor was brought on to assist with provider enrollment processing, the vacant supervisor position was filled with a temporarily assigned staff member, and recruitment for the unfilled provider enrollment contract specialist positions began as soon as the State hiring freeze was lifted. DHS intends to fill all open staff positions by the end of 2022, and if needed, will instruct the vendor to temporarily hire additional staff. Regarding the existing paper intensive process, a new online provider enrollment system (HOKU) that went into production on August 3, 2020 has reduced the paper application volume to less than 1% of all applications. Providers are now able to upload all pdf attachments to the HOKU application directly. There continues to be additional and on-going required upgrades to HOKU, to improve and streamline the provider enrollment experience. End Date: January 1, 2023
2020-004
The Department did not obtain the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Context: The requirement to obtain the MCOs? audited financial statements and to conduct or contract for an independent audit of the encounter and financial data submitted was a new program requirement for state fiscal year 2021. Cause: The Department was not aware of the requirements and therefore did not have policies and procedures in place to address the requirement. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: N/A
Show full finding ▾Hide full finding ▴Finding No.: 2021-004 Managed Care Financial Audit Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Special Tests and Provisions ? Managed Care Financial Audit Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2005HI5MAP 2020 2105HI5MAP 2021 Criteria: Pursuant to 42 CFR 438.3(m) the Department must require managed care organizations (MCOs), prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs) to submit audited financial reports, conducted in accordance with generally accepted accounting principles and generally accepted auditing standards, specific to its Medicaid contract on an annual basis. In addition, pursuant to 42 CFR 438.602(e), the Department must periodically, but no less frequently than once every 3 years, conduct, or contract for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. Condition: The Department did not obtain the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Context: The requirement to obtain the MCOs? audited financial statements and to conduct or contract for an independent audit of the encounter and financial data submitted was a new program requirement for state fiscal year 2021. Cause: The Department was not aware of the requirements and therefore did not have policies and procedures in place to address the requirement. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: N/A
Corrective Action Taken or Planned:Med-QUEST plans to procure services for this requirement and plans to have a contract in place prior to July 1, 2022. End Date: July 1, 2022
18 cases did not have supporting documentation or there were discrepancies between the information per the case management system and the supporting documentation for one or more key data elements. Context: We selected a non-statistical sample of 60 participant case files, out of a population of 7,850 based on the participants from two quarterly reports, for testing and noted the following: ? 1 out of 60 selections tested did not have supporting documentation for the date of eligibility determination ? 1 out of 60 selections tested did not have supporting documentation for the start date of employment in primary occupation ? 8 out of 60 selections tested had discrepancies between the date of application per the case management system and per the supporting documentation ? 8 out of 60 selections tested had discrepancies between the date of initial individualized plan for employment per the case management system and per the supporting documentation Cause: Although the Department has policies and procedures in place to ensure that the supporting documents are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: Without the appropriate documentation to support the key data elements reported, the Department is unable to demonstrate its compliance with the reporting requirements. Questioned Costs: None Identification of a repeat finding: This is a repeat finding of the most recent prior year audit 2020-006. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-005 Maintaining Proper Case Documentation Federal Agency: U.S. Department of Education Assistance Listing No.: 84.126 Program: Rehabilitation Services - Vocational Rehabilitation Grants to States Requirement: Reporting Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: H126A190015 2019 H126A200015 2020 Criteria: Rehabilitation Services Administration (RSA) Policy Directive RSA-PD-19-03 and 34 CFR 361.47 requires State Vocational Rehabilitation agencies to maintain supporting documentation (either hard copies or scanned copies) particularly regarding eligibility determinations, development of the individualized plan for employment, services provided, and case closure in the service record or case management system. Data reported in the case management system must match the supporting documentation for data elements containing critical information. Condition: 18 cases did not have supporting documentation or there were discrepancies between the information per the case management system and the supporting documentation for one or more key data elements. Context: We selected a non-statistical sample of 60 participant case files, out of a population of 7,850 based on the participants from two quarterly reports, for testing and noted the following: ? 1 out of 60 selections tested did not have supporting documentation for the date of eligibility determination ? 1 out of 60 selections tested did not have supporting documentation for the start date of employment in primary occupation ? 8 out of 60 selections tested had discrepancies between the date of application per the case management system and per the supporting documentation ? 8 out of 60 selections tested had discrepancies between the date of initial individualized plan for employment per the case management system and per the supporting documentation Cause: Although the Department has policies and procedures in place to ensure that the supporting documents are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: Without the appropriate documentation to support the key data elements reported, the Department is unable to demonstrate its compliance with the reporting requirements. Questioned Costs: None Identification of a repeat finding: This is a repeat finding of the most recent prior year audit 2020-006. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: 1. Review current internal control guidance by April 30, 2022. ? In September 2021, DVR issued a procedure under category ?Record of Service? entitled ?Use of Casefile Documents Checklist Form?. In this procedure, all Vocational Rehabilitation Specialists (VRS) are mandated to use the DHS2008 (REV 07/2021), Case File Documents Checklist Form, an internal control instrument designed to ensure all reportable individuals and participants of the Vocational Rehabilitation (VR) program have a case record of services that complies with the documentation and timeline requirements including the following: i. Required eligibility determination and IPE timelines ii. Filecontains all essentialsupporting documents including Certification of Eligibility for VR services signed and dated by the VRSalong with copies of all documentation from qualified personnel that assisted in determining eligibility/ineligibility. iii. Primary employment start date and supporting documents. iv. Ensure that all dates in the system match the supporting documentation for date of application and date of IPE. 2. Eligibility Determination Training ? General Eligibility Determination training was completed on January 24-26, 2022, with a recording and associated training documents uploaded to DVR shared drive so that it is accessible for review at any time for current and new VRS. A review of the documents required when determining eligibility will be conducted at the upcoming monthly SSO, Branch Administrator (BA), Supervisor meeting on March 31, 2022. This will befollowed by Branch meetings during the first two weeks in April where BAs and Supervisors will review and discuss current internal controls, the eligibility determination checklist, Supervisor/BA case closure procedures which are more qualitative reviews prior to a case being closed, and AWARE compliance reports for the Branchcounseling staff, in order to identify needed improvements. The April reviews at Branch level of the required eligibility documentation, procedures, status of compliance per monthly Branch Eligibility Determination reports, will be tracked in Branch minutes to validate staff attendance. Copies of the minutes will be shared with the VR Administrator by end of April 2022. ? DVR has planned an on-site eligibility training in the summer of 2022 to be conducted by the Rehabilitation Services Administration?s federally funded VR Technical Assistance Center for Quality Management (VRTAC-QM).A review of required documentation will be included in training. Staff training plans will document all staff completing this training. A recording of the training and associated documents will also be made available on DVR shared drive for staff to access. ? BAs/Supervisors will review all eligibility determinations for VRS I, VRS II, and new hires and enter case notes verifying review of each case record. 3. Review of federal and agency policy on Certification of Eligibility or Ineligibility and publish updated Eligibility Determination Procedures inclusive of eligibility extensions. ? Review of 34CFR 361.42 - Assessment for determining eligibility and priority for services at next monthly BA, Supervisor, SSO meeting on March 31, 2022. Confirm with staff this rule shall be adhered to when determining eligibility. ? Review of HDVR Policy, HAR 401.1-9.1 with BAs and Supervisors at next monthly SSO, Branch Administrator, Supervisor meeting on March 31, 2022, for the BA and Supervisor review and discussion with the respective Branch staff. Confirm with staff this policy shall be adhered to when determining eligibility. ? HDVR submitted draft Eligibility Determination Procedures January 30, 2022 for RSA?s comments/edits to finalize updates to internal controls.Eligibility-related internal controls procedures that will be included in HDVR?s Service Manual for Vocational Rehabilitation Specialist and Branch Administrators/Supervisors will be developed pending RSA?s comments/edits for the proposed updates to Eligibility Determination Procedures. HDVR?sService Manual for VRS and BAs/Supervisors will include eligibility-related internal controls once updates are completed.DVR expects to publish the final eligibility procedures by summer of 2022 prior to VRTAC-QM scheduled training and will include the requirement of supporting documentation for date of eligibility determination. Eligibility procedures supplement federal and state policies and BAs/Supervisors shall continue to comply with DVR?sexisting Eligibility Determination Policies 34CFR 361.42 and HAR 402.1-9.1. ? All BAs will be required to review the federal and state policy 34CFR 361.42 and HAR 401.1-9.1 and submit verification signed by all VR staff with eligibility determination assignments, including quality assurance reviews, to verify they have reviewed and understand the eligibility determination process. ? All BAs will review procedures with staff after they are finalized and submit to SSO verification signed by all VR staff, as applicable, that they have reviewed and understand the eligibility determination procedures. ? All BAs will continue to monitor compliance with documentation through qualitative reviews of eligibility determinations by VRS I, II, and newly hired VRS, as well as monthly review all requests for case closures, and case management system reports on timely eligibility compliance rates of 90%. For rates below 90%, BAs will meet with VRS I, II, III staff and their supervisor to identify strategies for compliance at 90% rate and monitor the identified staff compliance bi-weekly. 4. Ensure case management system parameters can support proper recording of eligibility determination that matches documentation by establishing rules for data input, i.e., date of eligibility can be recorded in Akamai-AWARE according to documentation requirements within 14-days of eligibility determination. Planned completion of this corrective action in summer 2022. 5. Reviewthe start date of employment in primary occupation per DVR?s internal controls to determine if further updates to internal controls are needed by April 30, 2022. ? Ensure that procedures and case management system parameters support proper recording of primary employment information including start date with supporting documentation. 6. Monthly Case File Audits ? All BAs and/or supervisors will continue to conduct 5 comprehensive case reviews monthly on active VR cases and record in DVR SharePoint site under each branch?s applicable folder located at: DHS DVR-Resources ? Documents ? CASE REVIEW ? MONTHLY BRANCH CASE REVIEWS for VRA, VRAA and SSO review. Reviews at the Branch level will include the following, but is not limited to areview of all eligibility determination documentation within the 60-day eligibility determination period (including eligibility extension, if applicable), all IPEs meet 90-day development/completion and meet all prescribed requirements according to policy; review of purchases and services provided; review of employment placement and dates of placement in primary employment; review of proper supporting documentation and that dates align with Akamai-Aware dates in all areas of review, and review of case notes to ensure that they thoroughly document the services provided for sustained compliance with policy and internal controls. ? Comprehensive case reviews will also be completed for every case closure prior to the supervisor?s approval to close. ? BA/Sups shall review all VRS I and VRS II cases on an ongoing basis while they are considered "trainees". ? SSO Specialist will conduct case review of 5 random cases monthly in addition to reviews by Supervisors and BAs. 7. Review and evaluate the need for updates to internal controls to ensure that date of application and initial individualized plan for employment match supporting documentation by April 30, 2022. ? Ensure that procedures and system parameters support proper recording of dates to align with supporting documentation on file. 8. BAs will develop action plans for their respective branches to ensure that compliance is met for all findings in this corrective action report by April 30, 2022. a. Ensure supporting documentation for the date of eligibility determination b. Ensure supporting documentation for the start date of employment in primary occupation c. Rectify discrepancies between the date of application per the case management system and per the supporting documentation d. Rectify discrepancies between the date of initial individualized plan for employment per the case management system and per the supporting documentation 9. BAs will develop and review with VRA for approval a branch corrective action plan to meet and sustain compliance associated with DVR?s internal controls and any identified deviations from monthly compliance reviews. End Date: June 30, 2022
2020-006
14 provider files did not contain the required documentation to support compliance with the provider eligibility requirement. Context: The process of qualifying as an eligible provider is the same for both the CHIP and Medicaid program. We selected a non-statistical sample of 60 providers for testing out of a population of approximately 5,800 providers. The providers selected for testing represented approximately $1.7 million of payments out of a total payment population of approximately $5.5 million. The results of our testing were as follows: ? 5 providers where the DHS Form-1139 was not maintained. ? 1 provider where documentation was missing which discloses the agreement of the providers to comply with disclosure requirements. ? 5 providers where the DHS Form-1139 did not support revalidation within the most recent 5-year period. ? 2 providers where the DHS Form-1139 did not support revalidation within the most recent 5-year period and the documentation to indicate whether the required pre-enrollment or post-enrollment on-site inspections were performed. ? 1 provider where the DHS Form-1139 was not maintained and documentation was missing to support the provider type and risk level and therefore we could not determine whether on-site visits were required. Cause: Although the Department has policies and procedures in place requiring the maintenance of required documentation and on-site visits, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement resulting in questioned costs. Questioned costs: $122,395 Identification of a repeat finding: N/A Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-006 Revalidation of Provider Eligibility Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.767 Program: Children?s Health Insurance Program Requirement: Special Tests and Provisions - Provider Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2005HI5021 2020 2105HI5021 2021 Criteria: The State Medicaid Agency, Department of Human Services, Med Quest Division is required to screen and enroll providers in accordance with 42 CFR Part 455, subpart E and make certain disclosures to the State Medicaid Agency in accordance with 42 CFR Part 455, subpart B. Pursuant 42 CFR 455.414, the State Medicaid agency must revalidate the enrollment of all providers regardless of provider type at least every 5 years. Pursuant to 42 CFR 455.432, the State Medicaid Agency must (a) conduct pre-enrollment site visits of providers who are designated as ?moderate? or ?high? categorical risks to the Medicaid program and (b) must require any enrolled provider to permit CMS, its agents, its designated contractors, or the State Medicaid Agency to conduct unannounced on-site inspections of any or all provider locations. Pursuant to 42 CFR 455 Subpart B, Providers are to comply with the requirements of the State Plan, including the disclosure requirement. The Department utilizes DHS Form-1139 as the provider application that screens and verifies licensure and enrollment in the program. DHS Form-1139 also documents the provider agreement to disclose information as required. Condition: 14 provider files did not contain the required documentation to support compliance with the provider eligibility requirement. Context: The process of qualifying as an eligible provider is the same for both the CHIP and Medicaid program. We selected a non-statistical sample of 60 providers for testing out of a population of approximately 5,800 providers. The providers selected for testing represented approximately $1.7 million of payments out of a total payment population of approximately $5.5 million. The results of our testing were as follows: ? 5 providers where the DHS Form-1139 was not maintained. ? 1 provider where documentation was missing which discloses the agreement of the providers to comply with disclosure requirements. ? 5 providers where the DHS Form-1139 did not support revalidation within the most recent 5-year period. ? 2 providers where the DHS Form-1139 did not support revalidation within the most recent 5-year period and the documentation to indicate whether the required pre-enrollment or post-enrollment on-site inspections were performed. ? 1 provider where the DHS Form-1139 was not maintained and documentation was missing to support the provider type and risk level and therefore we could not determine whether on-site visits were required. Cause: Although the Department has policies and procedures in place requiring the maintenance of required documentation and on-site visits, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement resulting in questioned costs. Questioned costs: $122,395 Identification of a repeat finding: N/A Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: Lack of staffing and a paper intensive process are the root causes of this finding. The State worker hiring freeze caused by the COVID pandemic further exacerbated the staffing issues. To remediate the staffing issue, a vendor was brought on to assist with provider enrollment processing, the vacant supervisor position was filled with a temporarily assigned staff member, and recruitment for the unfilled provider enrollment contract specialist positions began as soon as the State hiring freeze was lifted. DHS intends to fill all open staff positions by the end of 2022, and if needed, will instruct the vendor to temporarily hire additional staff. Regarding the existing paper intensive process, a new online provider enrollment system (HOKU) that went into production on August 3, 2020 has reduced the paper application volume to less than 1% of all applications. Providers are now able to upload all pdf attachments to the HOKU application directly. There continues to be additional and on-going required upgrades to HOKU, to improve and streamline the provider enrollment experience. End Date: January 1, 2023
The Department did not obtain the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Context: The requirement to obtain the MCOs? audited financial statements and to conduct or contract for an independent audit of the encounter and financial data submitted was a new program requirement for state fiscal year 2021. Cause: The Department was not aware of the requirements and therefore did not have policies and procedures in place to address the requirement. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: N/A
Show full finding ▾Hide full finding ▴Finding No.: 2021-007 Managed Care Financial Audit Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.767 Program: Children?s Health Insurance Program Requirement: Special Tests and Provisions ? Managed Care Financial Audit Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2005HI5021 2020 2105HI5021 2021 Criteria: Pursuant to 42 CFR 438.3(m) the Department must require managed care organizations (MCOs), prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs) to submit audited financial reports, conducted in accordance with generally accepted accounting principles and generally accepted auditing standards, specific to its Medicaid contract on an annual basis. In addition, pursuant to 42 CFR 438.602(e), the Department must periodically, but no less frequently than once every 3 years, conduct, or contract for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. Condition: The Department did not obtain the required audited financial reports and did not conduct or contract an independent audit of the encounter and financial data submitted. Context: The requirement to obtain the MCOs? audited financial statements and to conduct or contract for an independent audit of the encounter and financial data submitted was a new program requirement for state fiscal year 2021. Cause: The Department was not aware of the requirements and therefore did not have policies and procedures in place to address the requirement. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: N/A
Corrective Action Taken or Planned: Med-QUEST plans to procure services for this requirement and plans to have a contract in place prior to July 1, 2022. End Date: July 1, 2022
The Department did not properly credit the CMS-64 report for overpayments discovered. Context: The Department reported and refunded only collected overpayments, however overpayments discovered and not recovered were not reported and refunded. Cause: The Department was initially made aware of the requirements as a result of prior year?s audit, of the Medicaid program, however, policies and procedures were not put in place in time to take corrective action during the entire year. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: N/A Recommendations: We recommend the Department establish policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-008 Refunding of Medicaid Overpayments Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.767 Program: Children?s Health Insurance Program Requirement: Special Tests and Provisions - Refunding of Medicaid Overpayments Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2005HI5021 2020 2105HI5021 2021 Criteria: The State Medicaid Agency, Department of Human Services, Med Quest Division is required to refund the federal share of Medicaid overpayments made to providers in accordance with 42 U.S.C. 1396b and 42 CFR subpart F. Pursuant to 42 U.S.C. 1396b, the State Medicaid Agency has up to one year from the date of discovery of Medicaid overpayments to recover or attempt to recover the overpayments before the federal share must be refunded, regardless of whether recovery if made from the provider. Pursuant to 42 CFR 433.320(a)(2) the State Medicaid Agency must credit CMS with the Federal share of overpayments subject to recovery on the earlier of (1) the form CMS-64 submission due to CMS for the quarter in which the State recovers the overpayment from the provider; or (2) the form CMS-64 due to CMS for the quarter in which the 1-year period following discovery ends. Condition: The Department did not properly credit the CMS-64 report for overpayments discovered. Context: The Department reported and refunded only collected overpayments, however overpayments discovered and not recovered were not reported and refunded. Cause: The Department was initially made aware of the requirements as a result of prior year?s audit, of the Medicaid program, however, policies and procedures were not put in place in time to take corrective action during the entire year. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: N/A Recommendations: We recommend the Department establish policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: A new report template has been created and as of July 1, 2021, the MCOs will report quarterly on all active overpayments (either overpayments identified during the reporting period or identified in previous reporting periods but are still in active recovery). For these overpayments, Health Plans will report on the full amount of overpayment identified as well as the amount they have recovered. The MCOs will also report ad hoc on any overpayments from MQD they?ve identified through capitation (e.g., if they notice they receive capitation for a member who is deceased or who is duplicated). End Date: The Health Plans have already begun to submit this report as of February 2022.
No on-site reviews were conducted during the year. Context: The Department has a total of 11 subrecipients, none of which received an on-site review. Cause: Management indicated that the on-site reviews were not performed due to continued restrictions on travel due to COVID-19. Additionally, prior to the current year, management indicated that on-site reviews had not been conducted due to staffing issues. Effect: Failure to perform the required on-site reviews resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-007. Recommendations: We recommend that the Department implement risk assessment procedures and, in those situations where an on-site review would normally be required, the Department should devise alternative procedures in lieu of on-site reviews. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-009 Subrecipient Monitoring Federal Agency: U.S Department of Agriculture Assistance Listing No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance (SNAP) Cluster Requirement: Subrecipient Monitoring Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 7HI400HI4 2019 ? 2021, 7HI400HI6 2020 ? 2021 7HI430HI4 2019 ? 2021, 7HI400HI5 2019 ? 2022 7HI430HI5 2019 ? 2021, 8HI420000 2019 ? 2021 Criteria: CFR 200.332(b) requires the pass-thru entity to evaluate each subrecipient?s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring related to the subaward. 2 CFR 200.332(d) requires that the pass-thru entity monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward. In lieu of conducting a risk assessment as required by 2 CFR 200.332(b), the Department has adopted a policy to perform an annual audit for all subrecipients which includes a requirement for on-site reviews. Condition: No on-site reviews were conducted during the year. Context: The Department has a total of 11 subrecipients, none of which received an on-site review. Cause: Management indicated that the on-site reviews were not performed due to continued restrictions on travel due to COVID-19. Additionally, prior to the current year, management indicated that on-site reviews had not been conducted due to staffing issues. Effect: Failure to perform the required on-site reviews resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-007. Recommendations: We recommend that the Department implement risk assessment procedures and, in those situations where an on-site review would normally be required, the Department should devise alternative procedures in lieu of on-site reviews. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: Due to staffing changes and the on-going pandemic restrictions, only a limited amount of subrecipient monitoring could be done. The acting SNAPO Outreach specialist was able to conduct virtual subrecipient monitoring of nine subrecipients. Quarterly desk reviews of selected budget line items and desk reviews for invoices received during the quarter ended 06/21 were also conducted, however no site visits were conducted during FY 2021 due to the pandemic.As hiring for a permanent E&T program specialist is still on-going and pandemic restrictions continue, subrecipient monitoring and risk assessments will be conducted. End Date: September 30, 2022
2020-007
Discrepancies identified during the daily reconciliations were not investigated. Context: In response to a previous finding, the Department commenced performing the required daily reconciliation in February 2020. During the year, the Department?s daily reconciliations identified variances which ranged up to approximately $9.6 million. However, these variances were not investigated and there was no evidence that a review of the daily reconciliations was performed. Cause: The Department did not have written procedures in place to identify the required steps necessary, including a review, to ensure that any identified variances are resolved in a timely manner. Effect: Failure to resolve the reconciling items resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit 2020-008. Recommendations: We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliation is reviewed in a timely manner. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-010 EBT Reconciliation Federal Agency: U.S. Department of Agriculture Assistance Listing No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance (SNAP) Cluster Requirement: Special Tests and Provisions ? EBT Reconciliation Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 7HI400HI4 2019 ? 2021, 7HI400HI6 2020 ? 2021 7HI430HI4 2019 ? 2021, 7HI400HI5 2019 ? 2022 7HI430HI5 2019 ? 2021, 8HI420000 2019 ? 2021 Criteria: 7 CFR 274.4 requires that the Department perform daily reconciliations of all SNAP transactions between the State's Benefit Account, the US Treasury Department, and the EBT contractors. Condition: Discrepancies identified during the daily reconciliations were not investigated. Context: In response to a previous finding, the Department commenced performing the required daily reconciliation in February 2020. During the year, the Department?s daily reconciliations identified variances which ranged up to approximately $9.6 million. However, these variances were not investigated and there was no evidence that a review of the daily reconciliations was performed. Cause: The Department did not have written procedures in place to identify the required steps necessary, including a review, to ensure that any identified variances are resolved in a timely manner. Effect: Failure to resolve the reconciling items resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit 2020-008. Recommendations: We recommend that the Department develop procedures to ensure that identified variances are resolved and that the reconciliation is reviewed in a timely manner. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: FMO is in the process of creating new reports to identify the daily variances. Once these reports are created, we will be able to reconcile the EBT account daily. As of now, the reports we have do not provide the necessary information to identify these variances. FMO will also create written procedures on how to reconcile the EBT account. End Date:June 30, 2022
2020-008
Eligibility determinations for 20 participants were missing supporting documentation required by the State Plan, which encompasses the regulations above. Context: We selected a non-statistical sample of 60 case files which approximated $30,000 in monthly payments, out of a population of approximately 2,600 case files which approximated $15.3 million in total annual benefit payments, for testing and noted exceptions in 20 case files as follows: ? 16 case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of the monthly assistance paid. ? 1 case file where the ?difficulty of care? determination was missing and therefore did not support the assistance amount paid. ? 1 case file where documentation of the child?s special needs was missing. ? 12 case files where the state, FBI, and/or child abuse and neglect clearances were missing in the case files. Cause: Although the Department has established policies and procedures in place over the application process and documentation requirements to support the determination of assistance amounts, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements and resulted in questioned costs. Questioned Costs: $11,600 Identification of a repeat finding: N/A Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-011 Maintaining Proper Case Documentation to Support Eligibility Determinations Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.659 Program: Adoption Assistance Requirement: Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2001HIADPT 2020 2101HIADPT 2021 Criteria: Pursuant to 42 USC 673(a)(3), the amount of the adoption assistance payments to be made shall be determined through agreement between the adoptive parents and the State or local agency administering the program, which shall take into consideration the circumstances of the adopting parents and the needs of the child being adopted, and may be readjusted periodically, with the concurrence of the adopting parents (which may be specified in the adoption assistance agreement), depending upon changes in such circumstances. Pursuant to 42 USC 671(a)(20)(A), the State must have procedures for criminal records checks, including a fingerprint-based checks of national crime information databases (as defined in 28 USC 534(f)(3)(A)), for any prospective adoptive parent before the adoptive parent may be finally approved for placement of a child. Pursuant to 42 USC 671(a)(20)(B), the State shall check any child abuse and neglect registry maintained by the State for information on any prospective foster or adoptive parent and on any other adult living in the home of such prospective parent. Pursuant to 42 USC 673(a)(2)(A), the State must determine the child to have special needs in order to be eligible for adoption assistance payments. Condition: Eligibility determinations for 20 participants were missing supporting documentation required by the State Plan, which encompasses the regulations above. Context: We selected a non-statistical sample of 60 case files which approximated $30,000 in monthly payments, out of a population of approximately 2,600 case files which approximated $15.3 million in total annual benefit payments, for testing and noted exceptions in 20 case files as follows: ? 16 case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of the monthly assistance paid. ? 1 case file where the ?difficulty of care? determination was missing and therefore did not support the assistance amount paid. ? 1 case file where documentation of the child?s special needs was missing. ? 12 case files where the state, FBI, and/or child abuse and neglect clearances were missing in the case files. Cause: Although the Department has established policies and procedures in place over the application process and documentation requirements to support the determination of assistance amounts, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements and resulted in questioned costs. Questioned Costs: $11,600 Identification of a repeat finding: N/A Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: Effective immediately, the Social Services Division staff shall maintain proper documentation of Adoption Assistance cases. Social Service Assistants (SSAs) shall: 1) Complete the ?Adoption Assistance Agreement? (DHS 1578) by having the prospective/adoptive parent and the DHS representative sign the form and scanning and sending the electronic copy to the Management Information Compliance Unit (MICU) to verify its accuracy. a) Review their assigned Adoption cases to ensure the correct amount is reflective on ?Adoption Assistance Agreement?. b) If the amount(s) are incorrect, SSAs shall contact the prospective/adoptive parent immediately to have them sign an updated agreement form reflecting the correct rate of pay. 2) Verify the ?Difficulty of Care (DOC) Agreement? form is supplemented in the case record due to difficulties caring for a child as determined by the Social Worker. a) If the document is missing/incomplete, SSAs shall notify the Social Worker and execute an initial/revised DOC Agreement form. b) Verify that the ?difficulty of care? determination amount matches the assistance amount paid. 3) Ensure supporting DOC documentation of the child?s special needs is included in the case record. a) If the document is missing/incomplete, SSAs shall notify the Social Worker and execute the supporting DOC documentation of the child?s special needs. The Staff Development Office (SDO) staff shall provide training to the SSAs regarding maintaining proper documentation. Also, SDO must provide training to Licensing staff on processing and maintaining clearances. Both New Hire and Annual SSA Trainings conducted by SDO staff shall: 1) Include samples of ?The Adoption Assistance Agreement? and ?Difficulty of Care? forms. 2) Provide SSAs with information of the importance and instructions of completing both forms. Licensing staff shall: 1) Review all cases to ensure all national, state, FBI, and/or child abuse and neglect clearances are included in the licensing files. 2) Certify all clearances are valid. Otherwise, staff shall conduct clearances immediately of those that have expired. MICU staff shall: 1) Alert SSAs to complete the ?Adoption Assistance Agreement? form by populating the All-In Care Listing and proving staff with all children turning 6 years old and 12 years old each month. a) Verify the documents have been scanned electronically by the SSAs. 2) Continue working with internal auditors to follow-up with pending documents of cases that are selected to review. 3) Follow-up with the SSAs on missing/incomplete eligibility documents of assigned cases. Policies and procedures will be reviewed and updated, as needed, to support workflow and practice to meet specified requirements. Expected Completion Date: On-going
Eligibility determinations for 30 participants were missing supporting documentation required by the regulations above. Context: We selected a non-statistical sample of 60 case files which approximated $25,000 in monthly benefit payments, out of a population of approximately 600 case files which approximated $3.6 million in total annual benefit payments, for testing and noted exceptions in 30 case files as follows: ? 19 case files where the initial or modified guardianship agreements was missing and therefor did not support the monthly assistance paid. ? 5 case files where the DOC was missing or did not support the amount paid. ? 7 case files where the eligibility supporting documents such as birth certificate, court order, consent form and 6 months of foster care eligibility were missing in the case files. ? 6 case files where the state, FBI, and/or child abuse and neglect clearances were missing in the case files. ? 1 case file where a participant was receiving foster care and guardianship assistance payments in the same months. Cause: Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements and resulted in questioned costs. Questioned Costs: $9,170 Identification of a repeat finding: This is a repeat finding from the immediate previous audit 2020-010. Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-012 Maintaining Proper Case Documentation to Support Eligibility Determinations Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.090 Program: Guardianship Assistance Requirement: Eligibility, Activities Allowed or Unallowed, Allowable Cost Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2001HIGARD 2020 2101HIGARD 2021 Criteria: Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The "Guardianship/Permanency Assistance Agreement? (Agreement) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department, and includes the total amount of assistance payments. The Agreement may be further supplemented due to difficulties in caring for a child as determined by a caseworker on an as needed basis and documented on the ?Difficulty of Care? (DOC) worksheet. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 673(d)(3)(A), a child is eligible when the state agency determines the following: a) With respect to a child who has attained 14 years of age, the child has been consulted regarding the kinship guardianship arrangement. b) Eligible for foster care maintenance payments under 42 USC 672 while residing for at least six consecutive months in the home of the prospective relative guardian. c) Removed from his or her home pursuant to a voluntary placement agreement or as a result of a judicial determination to the effect that continuation in the home would be contrary to the welfare of the child. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Pursuant to 42 USC 671(a)(20)(c), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Condition: Eligibility determinations for 30 participants were missing supporting documentation required by the regulations above. Context: We selected a non-statistical sample of 60 case files which approximated $25,000 in monthly benefit payments, out of a population of approximately 600 case files which approximated $3.6 million in total annual benefit payments, for testing and noted exceptions in 30 case files as follows: ? 19 case files where the initial or modified guardianship agreements was missing and therefor did not support the monthly assistance paid. ? 5 case files where the DOC was missing or did not support the amount paid. ? 7 case files where the eligibility supporting documents such as birth certificate, court order, consent form and 6 months of foster care eligibility were missing in the case files. ? 6 case files where the state, FBI, and/or child abuse and neglect clearances were missing in the case files. ? 1 case file where a participant was receiving foster care and guardianship assistance payments in the same months. Cause: Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements and resulted in questioned costs. Questioned Costs: $9,170 Identification of a repeat finding: This is a repeat finding from the immediate previous audit 2020-010. Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Corrective Action Taken or Planned: Effective immediately, the Social Services Division (SSD) staff shall maintain proper documentation of Guardianship Assistance cases. Social Service Assistants (SSAs) shall: 1) Complete the ?The Guardianship/Permanency Assistance Agreement? (DHS 1663) by having the resource caregiver (RCG) and Section Administrator sign the form and scanning the electronic copy into the State of Hawaii Automated Keiki Assistance (SHAKA) system for the Management Information Compliance Unit (MICU) to verify its accuracy. a) Review their assigned Legal Guardianship cases to ensure the correct board amount is reflective on ?The Guardianship/Permanency Assistance Agreement?. b) If the amount(s) are incorrect, SSAs shall contact the relative provider immediately to have them sign an updated agreement form reflecting the correct rate of pay. 2) Verify the ?Difficulty of Care(DOC) Agreement? form is supplemented in the case record due to difficulties caring for a child as determined by the Social Worker. a) If the document is missing/incomplete, SSAs shall notify the Social Worker and execute an initial/revised DOC Agreement form. 3) Ensure eligibility supporting documents including the child?s birth certificate, court order, consent form and 6 months of foster board payments are included in the case record. Supervisors shall be responsible to remind staff to apply for the child?s birth certificate through the Department of Health and their social security card through the Social Security Administration immediately once the child enters foster care status. a) Any missing documents must be followed-up with immediately with the SSA by their Supervisors. b) Court orders shall be scanned into the SHAKA system for MICU to verify completion. 4) Verify the participant isn?t receiving both foster care and guardianship assistance payments simultaneously through the Child Protective Services System (CPSS) payment screens. The Staff Development Office (SDO) staff shall provide training to the SSAs regarding maintaining proper documentation including vital documents.Also, SDO must provide training to Licensing staff on processing and maintaining clearances. Both New Hire and Annual SSA Trainings conducted by SDO staff shall: 1) Include samples of ?The Guardianship/Permanency Assistance Agreement? and ?Difficulty of Care? forms. 2) Provide SSAs with information of the importance and instructions of completing both forms. Child Care Licensing staff shall: 1) Review all cases to ensure all national, state, FBI, and/or child abuse and neglect clearances are included in the licensing files. 2) Certify all clearances are valid. Otherwise, staff shall conduct clearances immediately of those that have expired. MICU staff shall: 1) Alert Social Services Assistants to complete the ?Guardianship/Permanency Assistance Agreement? form by populating the All-In Care Listing and proving staff with all children turning 6 years old and 12 years old each month. a) Verify the documents have been scanned electronically by the SSAs through SHAKA. 2) Continue working with internal auditors to follow-up with pending documents of cases that are selected to review. 3) Follow-up with the SSA?s on missing/incomplete eligibility documents of assigned cases. Expected Completion Date: June 30, 2022
2020-010
16 participants where the income information requested through IEVS did not agree to the information utilized to determine the participants benefit amount. Context: We selected a non-statistical sample of 60 case files for testing and noted 16 instances where the Department?s records did not support the use of the income information obtained through IEVS to evaluate or re-evaluate the benefit calculation. Cause: Program management indicated that there are policies and procedures in place regarding the use of the IEVS but these policies and procedures were not followed. Effect: Failure to properly use IEVS information to evaluate benefit amounts resulted in potential over payments of benefits. Questioned costs: $6,145 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-11. Recommendation: The Department should be more diligent in consistently following its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-013 Income Eligibility and Verification System Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.558 Program: Temporary Assistance for Needy Families (TANF) Requirement: Special Test ? Income Eligibility and Verification System Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 1402HITANF 2014, 1502HITANF 2015 1601HITANF 2016, 1801HITANF 2018 1901HITANF 2019, 2001HITANF 2020 2101HITANF 2021 Criteria: Title 45 CFR 205.55, requires the State agency to request through the Income Eligibility and Verification System (IEVS), wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Condition: 16 participants where the income information requested through IEVS did not agree to the information utilized to determine the participants benefit amount. Context: We selected a non-statistical sample of 60 case files for testing and noted 16 instances where the Department?s records did not support the use of the income information obtained through IEVS to evaluate or re-evaluate the benefit calculation. Cause: Program management indicated that there are policies and procedures in place regarding the use of the IEVS but these policies and procedures were not followed. Effect: Failure to properly use IEVS information to evaluate benefit amounts resulted in potential over payments of benefits. Questioned costs: $6,145 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-11. Recommendation: The Department should be more diligent in consistently following its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: The DHS 1006, Interview Documentation form, must be completed by the eligibility staff when interview is conducted and initial applications are processed. The form is also required when annual eligibility recertifications are processed for recipient families. Under Section XI of the DHS 1006 form lists the IEVS inquiries. It requires the eligibility staff to indicate which IEVS inquiries were completed. However, it does not include fields to require staff to document details such as date of query, findings, and what information were used for eligibility determination. Therefore, the DHS 1006 will be revised to create a new section specifically for IEVS and other third-party queries. The section will include fields that will require the eligibility staff to document details regarding their queries and information on their findings. After the DHS 1006 is revised, the form will be disseminated to the eligibility staff with instructions on how to complete the new IEVS section. End Date: September 30, 2022
2020-011
Eligibility re-determinations for 15 participants were not completed in accordance with the State Plan. Context: We selected a non-statistical sample of 60 participant files, representing approximately $36,000 of monthly benefit payments, out of a population of approximately 4,900 cases, representing approximately $28,000,000 of annual benefit payments, for testing. We noted exceptions in 15 case files where eligibility redeterminations were not completed in the timeframe required by the State Plan, resulting in potential benefit overpayments of $8,120. Cause: Due to the COVID-19 pandemic, the Department elected to suspend all eligibility redeterminations from December 2020 until July 2021. Although program changes are allowed, the Department was not aware of the requirement to submit an amendment to the State Plan within 30 days of the program change or to seek guidance from ACF on whether a particular action is allowable under program requirements. Effect: Failure to submit the plan amendment or to seek guidance from ACF on whether a particular action is allowable under program requirements, resulted in non-compliance with the requirement and potential questioned costs. Questioned Costs: $8,120 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-13. Recommendations: We recommend that the Department work with ACF to determine what remediation actions, if any, are required. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-014 Maintaining Proper Case Documentation to Support Eligibility Determinations Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.558 Program: Temporary Assistance for Needy Families (TANF) Requirement: Eligibility Type of Finding: Material Weakness and Non-Compliance Federal award no. and year: 1402HITANF 2014, 1502HITANF 2015 1601HITANF 2016, 1801HITANF 2018 1901HITANF 2019, 2001HITANF 2020 2101HITANF 2021 Criteria: The State of Hawaii Temporary Assistance for Needy Families State Plan (State Plan) states that a review of all eligibility requirements is required every 12 months for all TANF households. In addition, Administration for Children and Families (ACF) program instruction TANF-ACF-PI-2020-01 indicates that States may make program changes but must submit a plan amendment within 30 days of the program change. The program instruction also recommends that the State seek guidance from ACF on whether a particular action is allowable under program requirements. Condition: Eligibility re-determinations for 15 participants were not completed in accordance with the State Plan. Context: We selected a non-statistical sample of 60 participant files, representing approximately $36,000 of monthly benefit payments, out of a population of approximately 4,900 cases, representing approximately $28,000,000 of annual benefit payments, for testing. We noted exceptions in 15 case files where eligibility redeterminations were not completed in the timeframe required by the State Plan, resulting in potential benefit overpayments of $8,120. Cause: Due to the COVID-19 pandemic, the Department elected to suspend all eligibility redeterminations from December 2020 until July 2021. Although program changes are allowed, the Department was not aware of the requirement to submit an amendment to the State Plan within 30 days of the program change or to seek guidance from ACF on whether a particular action is allowable under program requirements. Effect: Failure to submit the plan amendment or to seek guidance from ACF on whether a particular action is allowable under program requirements, resulted in non-compliance with the requirement and potential questioned costs. Questioned Costs: $8,120 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-13. Recommendations: We recommend that the Department work with ACF to determine what remediation actions, if any, are required. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: ACF was consulted in December 2021. A letter will be submitted to notify ACF of the temporary amendments to the Hawaii TANF State Plan. End Date: April 30, 2022
2020-013
There were 10 participant files where documentation was missing to support whether or not the Department took appropriate action related to the participants? non-cooperation. Context: We selected a non-statistical sample of 25 participant files for testing out of a population of 241 participant files that were initially determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. We noted 10 participant files did not contain any correspondence, notices, or documentation to indicate whether any follow up action, up to and including case closure and cessation of benefits, were performed. Consequently, there may be potential overpayments of benefits of $40,038. Cause: There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Effect: Failure to retain documentation to support a determination that appropriate action was taken limits the Department?s ability to demonstrate compliance with the requirement and resulted in questioned costs. Questioned Costs: $40,038 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-12. Recommendations: We recommend that the Department diligently perform the required procedures until its proposed system based corrective actions are completed. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-015 Maintaining Proper Case Documentation to Support Compliance with Child Support Non-Cooperation Requirement Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.558 Program: Temporary Assistance for Needy Families (TANF) Requirement: Special Tests and Provisions - Child Support Non-Cooperation Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 1402HITANF 2014, 1502HITANF 2015 1601HITANF 2016, 1801HITANF 2018 1901HITANF 2019, 2001HITANF 2020 2101HITANF 2021 Criteria: 45 CFR section 264.30 states the Title IV-A agency must take appropriate action, as defined, if the Title IV-D agency determines that an individual is not cooperating with the child support enforcement requirements. Condition: There were 10 participant files where documentation was missing to support whether or not the Department took appropriate action related to the participants? non-cooperation. Context: We selected a non-statistical sample of 25 participant files for testing out of a population of 241 participant files that were initially determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. We noted 10 participant files did not contain any correspondence, notices, or documentation to indicate whether any follow up action, up to and including case closure and cessation of benefits, were performed. Consequently, there may be potential overpayments of benefits of $40,038. Cause: There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Effect: Failure to retain documentation to support a determination that appropriate action was taken limits the Department?s ability to demonstrate compliance with the requirement and resulted in questioned costs. Questioned Costs: $40,038 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2020-12. Recommendations: We recommend that the Department diligently perform the required procedures until its proposed system based corrective actions are completed. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: Notice of CSEA Non-Compliance is transmitted via system interface between KEIKI and HAWI. Notices appear in HAWI as Eligibility Worker Alerts (EWALs). When operations were based on caseload management (i.e., cases were assigned to eligibility workers), the EWALs were managed, and actions were completed by the assigned eligibility workers. However, operations are no longer operating caseload management style but as task-oriented process. Therefore, cases are not reviewed in the system unless a client applies, reports a mandatory change, at point of 6-month simplified reporting, or at annual recertification. CSEA non-compliance alerts are outside of these processes unless the Processing Centers receive emails or faxed notifications from CSEA. Otherwise, actions are not taken on any system interface alerts of CSEA non-compliance until a case is worked on in HAWI. No system modifications will be made to the HAWI system because we are currently building a new eligibility system that will replace HAWI in its entirety. As a temporary solution, at the beginning of each month, we will request the Office of Information Technology (OIT) to run monthly ad hoc reports to capture all EWALs received from the KEIKI system. The ad hoc reports will be disseminated to the affected Processing Centers to take appropriate action. End Date: September 30, 2022
2020-012
Reports for 7 subawards were not submitted timely. Context: We selected 7 out of 62 subawards for testing and noted the following: Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements 7 0 7 0 0 Dollar amount of Tested Transactions Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements $1,700,000 $0 $1,700,000 $0 $0 Cause: Program management indicated that they were unaware that there was a deadline to submit the reports online. Effect: Failure to submit the reports timely resulted in non-compliance of the requirement. Questioned costs: N/A Identification of a repeat finding: N/A Recommendation: The Department should establish policies and procedures to ensure compliance with the requirement. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-016 Special Reporting for Federal Funding Accountability and Transparency Act Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.558 Program: Temporary Assistance for Needy Families (TANF) Requirement: Reporting Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: 2101HITANF 2021 Criteria: 2 CFR part 170, requires recipients of grants to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). For subaward information, the report should be submitted no later than the end of the month following the month in which the obligation was made. Condition: Reports for 7 subawards were not submitted timely. Context: We selected 7 out of 62 subawards for testing and noted the following: Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements 7 0 7 0 0 Dollar amount of Tested Transactions Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements $1,700,000 $0 $1,700,000 $0 $0 Cause: Program management indicated that they were unaware that there was a deadline to submit the reports online. Effect: Failure to submit the reports timely resulted in non-compliance of the requirement. Questioned costs: N/A Identification of a repeat finding: N/A Recommendation: The Department should establish policies and procedures to ensure compliance with the requirement. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: Subawards will be entered into the FSRS within the appropriate timeframe following the execution of the contract. End Date: Not applicable as reporting of federal subawards is an on-going requirement.
1 case file where a participant?s benefit calculation was not supported by the documents retained in the SNAP system. Context: We selected a non-statistical sample of 60 participant files which approximated $39,000 in monthly payments, out of a population of approximately 105,000 participant files which approximated $863 million in total annual benefit payments, for testing and noted 1 case file where income information was entered manually did not agree to the documentation retained in participant?s case file, resulting in an overpayment of benefits of $30 per month. Cause: There was a likely clerical error during the manual input of income information. Effect: A participant received excess benefits resulting in questioned costs. Questioned Costs: $30 Identification of a repeat finding: Not applicable Recommendations: We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant?s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-017 Maintaining Proper Case Documentation to Support Eligibility Determinations Federal Agency: U.S. Department of Agriculture Assistance Listing No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance (SNAP) Cluster Requirement: Special Tests and Provisions ? ADP System for SNAP Type of Finding: Known Questioned Costs When Likely Questioned Costs Are Greater Than $25,000 Federal award no. and year: 7HI400HI4 2019 ? 2021, 7HI400HI6 2020 ? 2021 7HI430HI4 2019 ? 2021, 7HI400HI5 2019 ? 2022 7HI430HI5 2019 ? 2021, 8HI420000 2019 ? 2021 Criteria: Per 7 CFR 272.10(b)(1)(i) the SNAP system should be sufficiently automated to determine eligibility and calculate benefits or validate the eligibility worker's calculations by processing and storing all casefile information necessary for the eligibility determination and benefit computation (including but not limited to all household members' names, addresses, dates of birth, social security numbers, individual household members' earned and unearned income by source, deductions, resources and household size). Condition: 1 case file where a participant?s benefit calculation was not supported by the documents retained in the SNAP system. Context: We selected a non-statistical sample of 60 participant files which approximated $39,000 in monthly payments, out of a population of approximately 105,000 participant files which approximated $863 million in total annual benefit payments, for testing and noted 1 case file where income information was entered manually did not agree to the documentation retained in participant?s case file, resulting in an overpayment of benefits of $30 per month. Cause: There was a likely clerical error during the manual input of income information. Effect: A participant received excess benefits resulting in questioned costs. Questioned Costs: $30 Identification of a repeat finding: Not applicable Recommendations: We recommend the Department emphasize the importance of diligently checking that any information entered manually agrees to the supporting documentation retained in the participant?s file. We also recommend the Department consider implementing a secondary review of participant files where information affecting the calculation of benefits is entered manually. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: On February 9, 2022, SNAP office reminded the processing centers staff to ensure that supporting documents are placed in the system ? client?s electronic case folder, HAWI case notes, documentation in DHS 1006, if applicable, when calculating income and benefits. Any information entered manually must be consistent with the documentation placed or stored in the system and case file. Supervisors or quality maintenance workers will randomly review case files documentation and benefit calculations entered manually. Staff was also reminded to refer to the verification requirement desk aids available in SharePoint as well as the existing program clarification on Income Projection and Budgeting, PC 18-014. Likewise, SNAP office will ask the Staff Development Office to ensure that this information is covered and emphasized in the training of new eligibility workers. End Date: June 30, 2022
Documentation of reviews performed for the DHS Form 1494, Form 1495, and/or Form 1050 was not maintained for 2 processing centers. Context: We selected a non-statistical sample of 4 processing centers out of the Department?s 20 processing centers and noted that supervisor reviews performed over the DHS Form 1494, Form 1495, and/or Form 1050 was not maintained at 2 processing centers. Cause: Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require a supervisor sign-off documenting their review resulting in the inconsistent application of documentation of supervisor reviews. Effect: Documentation of supervisor approval of the review over the DHS Form 1494, Form 1495, and/or Form 1050 was not maintained at 2 processing centers increasing the risk of non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate prior audit. See finding no 2020-009. Recommendations: We recommend the Department modify their policies and procedures to explicitly require supervisor sign-offs documenting their review. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2021-018 EBT Card Security Federal Agency: U.S. Department of Agriculture Assistance Listing No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance (SNAP) Cluster Requirement: Special Tests and Provisions ? EBT Card Security Type of Finding: Significant Deficiency Federal award no. and year: 7HI400HI4 2019 ? 2021, 7HI400HI6 2020 ? 2021 7HI430HI4 2019 ? 2021, 7HI400HI5 2019 ? 2022 7HI430HI5 2019 ? 2021, 8HI420000 2019 ? 2021 Criteria: 7 CFR 274.8(b)(3) requires the Department to ensure there are storage and control measures to control blank unissued electronic benefit transfer (EBT) cards. To address this requirement, the Department has adopted a policy that requires (1) monthly or quarterly review of the DHS Form 1494, Bulk Inventory Control Log; (2) daily or weekly review of the DHS Form 1495, Hawaii EBT Card Daily Control Log; and (3) monthly review of the DHS Form 1050, EBT Card Destruction Control Log. Condition: Documentation of reviews performed for the DHS Form 1494, Form 1495, and/or Form 1050 was not maintained for 2 processing centers. Context: We selected a non-statistical sample of 4 processing centers out of the Department?s 20 processing centers and noted that supervisor reviews performed over the DHS Form 1494, Form 1495, and/or Form 1050 was not maintained at 2 processing centers. Cause: Although the Department has policies and procedures in place regarding reviews, the policies and procedures do not explicitly require a supervisor sign-off documenting their review resulting in the inconsistent application of documentation of supervisor reviews. Effect: Documentation of supervisor approval of the review over the DHS Form 1494, Form 1495, and/or Form 1050 was not maintained at 2 processing centers increasing the risk of non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate prior audit. See finding no 2020-009. Recommendations: We recommend the Department modify their policies and procedures to explicitly require supervisor sign-offs documenting their review. Views of Responsible Officials and Planned Corrective Action: See Part VI Corrective Action Plan.
Corrective Action Taken or Planned: The EBT Office will revise forms DHS 1494, DHS 1495, and DHS 1050 to add an additional column where the unit supervisors can initial to indicate that the various card audits took place. End Date: June 30, 2022
2020-009
FAC accepted this audit on March 24, 2021 — management decision was due September 24, 2021.
Eligibility determinations for both MAGI and MAGI-excepted initial applications were not processed in accordance with the time standards. Additionally, eligibility re-verifications were not completed in a timely manner. Context: We obtained the monthly CMS Performance Metrics Report, which the Department uses to report the timeliness of initial eligibility determinations and re-verifications, and noted that there were approximately 64,000 applications received during fiscal year 2020. Based on the monthly CMS Performance Metrics Report, which identifies the number of applicants that were not processed timely at the end of the month, KMH computed a monthly average of approximately 70 MAGI applications and approximately 5 MAGI excepted applications where the initial eligibility was not determined within the timeframe as defined. Additionally, there were approximately 282,000 re-verifications processed during fiscal year 2020 and KMH computed a monthly average of approximately 2,500 cases where the re-verification was not completed within 12 months. Cause: Management indicated that there was a lack of training and standard operating procedures to ensure initial eligibility determination and re-verifications were completed timely. Effect: The Department was not in compliance with the requirement to determine eligibility in a timely manner. Questioned costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-002. Recommendations: We recommend the Department implement training and standard operating procedures to ensure eligibility determinations is completed in a timely manner. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-002 Complete Eligibility Applications and Annual Eligibility Re - Verifications in a Timely Manner Federal Agency: U.S Department of Health and Human Services CFDA No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. 1905HI5MAP 2019 and year: 2005HI5MAP 2020 Criteria: Title 42 CFR Part 435.911 requires the timely determination of eligibility of individuals who apply for Medicaid benefits within 1) ninety days for applicants who apply for Medicaid on the basis of disability (MAGI-excepted), and 2) forty five days for all other applicants (MAGI). In addition, Title 42 CFR Part 435.916 requires annual re-verifications of participant eligibility. Condition: Eligibility determinations for both MAGI and MAGI-excepted initial applications were not processed in accordance with the time standards. Additionally, eligibility re-verifications were not completed in a timely manner. Context: We obtained the monthly CMS Performance Metrics Report, which the Department uses to report the timeliness of initial eligibility determinations and re-verifications, and noted that there were approximately 64,000 applications received during fiscal year 2020. Based on the monthly CMS Performance Metrics Report, which identifies the number of applicants that were not processed timely at the end of the month, KMH computed a monthly average of approximately 70 MAGI applications and approximately 5 MAGI excepted applications where the initial eligibility was not determined within the timeframe as defined. Additionally, there were approximately 282,000 re-verifications processed during fiscal year 2020 and KMH computed a monthly average of approximately 2,500 cases where the re-verification was not completed within 12 months. Cause: Management indicated that there was a lack of training and standard operating procedures to ensure initial eligibility determination and re-verifications were completed timely. Effect: The Department was not in compliance with the requirement to determine eligibility in a timely manner. Questioned costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-002. Recommendations: We recommend the Department implement training and standard operating procedures to ensure eligibility determinations is completed in a timely manner. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Views of responsible officials: Based on the context detailed here, we find that the vast majority, 99%, of all eligibility applications received were processed in a timely manner. We also understand that the data collected indicates 90% of all re-verifications happened in a timely manner. Additionally, Hawaii applied for and was granted a waiver to delay processing eligibility redeterminations (ERs) during the Health and Human Services declared Public Health Emergency (PHE) in order to leverage the 6.2% increased federal cost-share available to states under the Families First Coronavirus Response Act (FFCRA). States were required to ensure that all individuals who were either enrolled or became enrolled on or after March 18, 2020 remained enrolled during the PHE. The PHE has been extended several times and is currently scheduled to end April 20, 2021. This rule changed the way we currently approach eligibility redeterminations in order to maintain active enrollments during the PHE. Corrective Action Taken or Planned: CMS has recently provided new guidance on how to redetermine eligibility while maintaining enrollment during the PHE. MQD is developing plans for how we will unwind from the PHE once it ends including how we will act on eligibility redeterminations. We just began redeterminations for passive renewals in February 2021. Additionally, we have completed the creation of new training materials that further reinforce the steps for timely eligibility determinations and redeterminations. Expected Completion Date: These efforts are on-going and we anticipate full restoration of our eligibility redetermination schedule at the conclusion of the PHE. Responding Official: Lori Lei Aponte, MQD Eligibility Branch Administrator (TA)
2019-002
The Department did not properly credit the CMS-64 report for overpayments discovered. Context: The Department reported and refunded only collected overpayments, however overpayments discovered and not recovered were not reported and refunded. Cause: The Department was not aware of the requirements which led to the lack of proper policies and procedures in place. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: N/A Recommendations: We recommend the Department establish policies and procedures to ensure compliance with the program requirements, and to follow them diligently. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-003 Refunding of Medicaid Overpayments Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Special Tests and Provisions ? Refunding of Federal Share of Medicaid Overpayments to Providers Type of Finding: Non-Compliance and Material Weakness Federal award no. 1905HI5MAP 2019 and year: 2005HI5MAP 2020 Criteria: The State Medicaid Agency, Department of Human Services, Med Quest Division is required to refund the federal share of Medicaid overpayments made to providers in accordance with 42 U.S.C. 1396b and 42 CFR subpart F. Pursuant to 42 U.S.C. 1396b, the State Medicaid Agency has up to one year from the date of discovery of Medicaid overpayments to recover or attempt to recover the overpayments before the federal share must be refunded, regardless of whether recovery is made from the provider. Pursuant to 42 CFR 433.320(a)(2) the State Medicaid Agency must credit CMS with the Federal share of overpayments subject to recovery on the earlier of (1) the form CMS-64 submission due to CMS for the quarter in which the State recovers the overpayment from the provider; or (2) the form CMS-64 due to CMS for the quarter in which the 1-year period following discovery ends. Condition: The Department did not properly credit the CMS-64 report for overpayments discovered. Context: The Department reported and refunded only collected overpayments, however overpayments discovered and not recovered were not reported and refunded. Cause: The Department was not aware of the requirements which led to the lack of proper policies and procedures in place. Effect: The Department was not in compliance with the requirements. Questioned costs: N/A Identification of a repeat finding: N/A Recommendations: We recommend the Department establish policies and procedures to ensure compliance with the program requirements, and to follow them diligently. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Views of responsible officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: We will take steps to establish policies and procedures to gather information from each Managed Care Organization (MCO) on overpayments that are both discovered and recovered. Revisions were made to the MCO request for proposals (RFPs) to clarify that identified overpayments must be reported in full, not only recovered overpayments. MQD is working on developing new reports for the health plans which delineate identified overpayments. The policies need to ensure amounts are not reported twice. Expected Completion Date: June 30, 2022 Responding Official: Eric Nouchi, MQD Finance Officer
Required screening and enrollment for 9 providers was not properly supported by the Department?s records and the Medicaid Application/Change Request Form (Form DHS 1139). Required pre-enrollment on-site inspections were not performed or documented for 2 providers. Also, a record of criminal background check was not maintained for 1 provider. Context: We selected a non-statistical sample of 90 providers for testing out of a population of approximately 7,700 providers. The providers selected for testing represented approximately $906,000 of payments out of a total payment population of approximately $101 million. The results of our testing were as follows: ? 4 providers where the Form DHS 1139 was not maintained. ? 5 providers where an updated Form DHS 1139 was not maintained. ? 2 providers where the on-site visit documentation was not maintained. ? 1 provider where the license and criminal background check were not maintained. Cause: Although the Department has policies and procedures in place requiring the maintenance of required documentation and on-site visits, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement resulting in potential questioned costs. Questioned costs: $444,170 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-004. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-004 Revalidation of Provider Eligibility Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Special Tests and Provisions - Provider Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. 1905HI5MAP 2019 and year: 2005HI5MAP 2020 Criteria: The State Medicaid Agency, Department of Human Services, Med Quest Division is required to screen and enroll providers in accordance with 42 CFR Part 455, subpart E and make certain disclosures to the State Medicaid Agency in accordance with 42 CFR Part 455, subpart B. Pursuant 42 CFR 455.414, the State Medicaid agency must revalidate the enrollment of all providers regardless of provider type at least every 5 years. Pursuant to 42 CFR 455.432, the State Medicaid Agency must (a) conduct pre-enrollment site visits of providers who are designated as ?moderate? or ?high? categorical risks to the Medicaid program and (b) must require any enrolled provider to permit CMS, its agents, its designated contractors, or the State Medicaid Agency to conduct unannounced on-site inspections of any or all provider locations. Pursuant to 42 CFR 455.434, the State Medicaid Agency must require providers to submit criminal background checks including finger printing for those designated as "high" categorical risks to the Medicaid program. Condition: Required screening and enrollment for 9 providers was not properly supported by the Department?s records and the Medicaid Application/Change Request Form (Form DHS 1139). Required pre-enrollment on-site inspections were not performed or documented for 2 providers. Also, a record of criminal background check was not maintained for 1 provider. Context: We selected a non-statistical sample of 90 providers for testing out of a population of approximately 7,700 providers. The providers selected for testing represented approximately $906,000 of payments out of a total payment population of approximately $101 million. The results of our testing were as follows: ? 4 providers where the Form DHS 1139 was not maintained. ? 5 providers where an updated Form DHS 1139 was not maintained. ? 2 providers where the on-site visit documentation was not maintained. ? 1 provider where the license and criminal background check were not maintained. Cause: Although the Department has policies and procedures in place requiring the maintenance of required documentation and on-site visits, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement resulting in potential questioned costs. Questioned costs: $444,170 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-004. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the program requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
View of responsible official: The Department agrees with the findings and will implement corrective action. The Department has shared with the auditors in the past that the section that is responsible for provider enrollment continues to be short-staffed. Currently, there is a temporarily assigned (TA) supervisor, a single full-time contract specialist, and two full-time clerical staff. Two open contract specialist professional positions continue to be vacant and these vacancies have contributed to the lack of diligence in complying with the policies and procedures. With an effective on-going hiring freeze because of the COVID-19 public health emergency, the section is struggling to continue to meet the 42 CFR requirements. Corrective Action Taken or Planned: The Department went live with HOKU, our new web-based provider enrollment system, on August 3, 2020 after several delays from the initial go-live date of March 2020. The HOKU system is expected to allow the Department to adhere to and comply with the policies and procedures outlined in 42 CFR 455 Subparts B and E. We decided on and completed a phased go-live approach in December 2020, recognizing the limited staffing that is available to the Department to register providers into HOKU. This approach had the Department sending HOKU registration `invitation? letters to providers in four approximately equal-sized `waves? based on provider type, occurring from go-live until the end of 2020. We continue to partner with our vendor Koan to staff the provider call center and provider application processing. Provider training for the HOKU system is accomplished via a three-prong approach ? `live? scheduled webinar training, YouTube training videos, and PDF slide deck training - all of which can be accessed from our HOKU website at https://medquest.hawaii.gov/HOKU. The Department has an assigned Project Manager to manage the HOKU project implementation and operational aspects, and has additionally assigned a TA supervisor for the provider enrollment section in the latter part of 2019 to provide daily oversight as well as management and problem solving around the HOKU implementation. Development of an internal staff library of policies and procedures is on-going and will be made available to all staff and vendors working on provider enrollment. Internal staff meetings continue to be held daily to identify provider enrollment issues and solution development and include the vendor Koan on an intermittent basis. Daily post go-live calls have converted to weekly with the HOKU vendor CNSI to address ongoing system updates, problems, and needed configuration. As of mid-February 2021, the Department has completed the registration of 853 providers Expected Completion Date: On-going, tentatively the end of 2021. Responding Official: Jon Fujii, MQD Health Care Services Branch Administrator
2019-004
Program income amounts were not disbursed prior to requesting additional funds. Context: During our audit, we noted approximately $1,021,000 of program income was received throughout the year, however, it was not consistently disbursed prior to requesting additional funds from the Department of Education. The Department maintained a program income balance of approximately $255,000 at June 30, 2020. Cause: The Department developed policies and procedures over program income during the year, however, there was a lack of diligence in following the policies and procedures to ensure program income funds were utilized prior to requesting additional funds. Effect: Failure to disburse program income before requesting additional funds resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding of the most recent prior year audit 2019-005. Recommendations: We recommend the Department be more diligent in following its policies and procedures over program income to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-005 Program Income Federal Agency: U.S. Department of Education CFDA No.: 84.126 Program: Rehabilitation Services - Vocational Rehabilitation Grants to States Requirement: Program Income Type of Finding: Non-Compliance and Material Weakness Federal award no. H126A200015 2020 and year: Criteria: 34 CFR 361.63 requires the Department to disburse program income funds before requesting additional funds from the Department of Education. Condition: Program income amounts were not disbursed prior to requesting additional funds. Context: During our audit, we noted approximately $1,021,000 of program income was received throughout the year, however, it was not consistently disbursed prior to requesting additional funds from the Department of Education. The Department maintained a program income balance of approximately $255,000 at June 30, 2020. Cause: The Department developed policies and procedures over program income during the year, however, there was a lack of diligence in following the policies and procedures to ensure program income funds were utilized prior to requesting additional funds. Effect: Failure to disburse program income before requesting additional funds resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding of the most recent prior year audit 2019-005. Recommendations: We recommend the Department be more diligent in following its policies and procedures over program income to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Views of responsible officials: The Department agrees with the finding and corrective action will be implemented. Corrective Action Taken or Planned: 1. DVR has drafted internal control updates, ?FFY21 Annual Allocation of Program Income for allowable, reasonable, and allocable expenditures in compliance with federal and state regulations, as overseen by DVR management in collaboration with DHS FMO Accountant? expected to be updated and finalized by May 31, 2021 and will include clarification in procedures of roles and responsibilities of staff and proper tracking, reporting, and disbursement of program income prior to drawdown of Federal funds. This update will reference existing internal controls, including DVR?s Period of Performance procedures. 2. DVR will continue to work with State Budget and Finance for guidance on State policies associated with federal requirements for program income spending and period of performance. 3. DVR is also working with Rehabilitation Services Administration (RSA) and/or WINTAC to obtain technical assistance with federal funder to ensure updates of Program Income internal controls for policies and procedure are in compliance with the most current federal and state regulations. 4. DVR Staff Services Office (SSO) Subject Matter Expert (SME) will partner with FMO accountant to provide all applicable staff with training and guidance on the proper tracking, reporting, and disbursement of program income. 5. Copies of staff training logs will be maintained by DVR SSO for all staff. Expected Completion Date: June 2021 Responding Officials: Maureen Bates, VR Administrator and Iva Cain, VR Assistant Administrator
2019-005
14 cases did not have supporting documentation or there were discrepancies between the information per the case management system and the supporting documentation for one or more key data elements. Context: We selected a non-statistical sample of 60 participant case files, out of a population of 7,699 based on the participants from two quarterly reports, for testing and noted exceptions in 14 case files as follows: ? 2 cases did not have the eligibility determination form to support the date of eligibility determination ? 1 case did not have the individualized plan for employment (IPE) to support the date of most recent or amended IPE ? 2 cases did not have supporting documentation (i.e. paystubs) for the start date of employment in primary occupation ? 1 case did not have supporting documentation (i.e. paystubs) for the employment outcome at exit and for the hourly wage at exit ? 6 cases had discrepancies between the date of application per the case management system and per the application form ? 1 case had a discrepancy between the date of eligibility determination per the case management system and the date per the eligibility determination form ? 4 cases had discrepancies between the date of most recent or amended IPE per the case management system and the IPE Cause: Although the Department has policies and procedures in place to ensure that the supporting documents are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: Without the appropriate documentation to support the key data elements reported, the Department is unable to demonstrate its compliance with the reporting requirements. Questioned Costs: None Identification of a repeat finding: This is a repeat finding of the most recent prior year audit 2019-006. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-006 Maintaining Proper Case Documentation Federal Agency: U.S. Department of Education CFDA No.: 84.126 Program: Rehabilitation Services - Vocational Rehabilitation Grants to States Requirement: Reporting Type of Finding: Non-Compliance and Material Weakness Federal award no. H126A180015 2018 and year: H126A190015 2019 H126A200015 2020 Criteria: Rehabilitation Services Administration (RSA) Policy Directive RSA-PD-16-04 and 34 CFR 361.47 requires State Vocational Rehabilitation agencies to maintain supporting documentation (either hard copies or scanned copies) particularly regarding eligibility determinations, development of the individualized plan for employment, services provided, and case closure in the service record or case management system. Data reported in the case management system must match the supporting documentation for data elements containing critical information. Condition: 14 cases did not have supporting documentation or there were discrepancies between the information per the case management system and the supporting documentation for one or more key data elements. Context: We selected a non-statistical sample of 60 participant case files, out of a population of 7,699 based on the participants from two quarterly reports, for testing and noted exceptions in 14 case files as follows: ? 2 cases did not have the eligibility determination form to support the date of eligibility determination ? 1 case did not have the individualized plan for employment (IPE) to support the date of most recent or amended IPE ? 2 cases did not have supporting documentation (i.e. paystubs) for the start date of employment in primary occupation ? 1 case did not have supporting documentation (i.e. paystubs) for the employment outcome at exit and for the hourly wage at exit ? 6 cases had discrepancies between the date of application per the case management system and per the application form ? 1 case had a discrepancy between the date of eligibility determination per the case management system and the date per the eligibility determination form ? 4 cases had discrepancies between the date of most recent or amended IPE per the case management system and the IPE Cause: Although the Department has policies and procedures in place to ensure that the supporting documents are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: Without the appropriate documentation to support the key data elements reported, the Department is unable to demonstrate its compliance with the reporting requirements. Questioned Costs: None Identification of a repeat finding: This is a repeat finding of the most recent prior year audit 2019-006. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Views of responsible officials: The Department agrees with the finding and corrective action will be implemented. Corrective Action Taken or Planned: 1. DVR issued an ICF Directive: Timeliness for Processing Applications, Eligibility Determinations and the Individualized Plans for Employment in February 2021 to reaffirm DVR?s commitment to and compliance with both Federal Regulations and State Policy that ensure the timeliness of services during the VR process specific to referral, application, eligibility determination and development of the Individualized Plan for Employment (IPE). This document reinforces the timelines for eligibility determinations (60 days from date of application), IPE development (signed within 90 days of eligibility determination) and the need for source documentation to validate activity at each level of the VR process (clearly identified, labeled, and uploaded into Aware as well as filed in hard copy case file). All Branch Administrators (BA) are required to review with staff by March 31, 2021 and submit to Staff Services Office (SSO) (template provided by SSO) verification signed by all VR staff, as applicable, that they have reviewed and understand the timelines and documentation required at each level of activity, uploading into Akamai-Aware with proper labeling of documents, and filing the documents in the hard copy case file. 2. All staff will be required to review the following federal and regulations and Hawaii Administrative Rules (HAR): a. 34CFR 361.41?Processing referrals and applications b. 34 CFR 361.42?Assessment for determining eligibility and priority for services c. 34 CFR 361.43?Procedures for Ineligibility Determination d. 34CRF 361.44?Closure without Eligibility Determination e. 34CFR 361.45?Development of the IPE f. 34CFR 361.46?Content of the IPE g. 34CFR 361.47?Record of Services h. HAR 401.1-3 ? Information and referral i. HAR 401.1-4 ? Referral and Application j. HAR 401.1-7 ? Assessment for Determining Eligibility and Priority for Services k. HAR 401.1-10 ? Development of the IPE l. HAR 401.1-11 ? Content of the IPE m. HAR 401.1-34 ? Record of Services n. HAR 401.1-36- Requirements for Successful Closures o. Procedure: Evaluation of Competitive Integrated Employment, issued November 2, 2020 p. Procedure: Performance Indicators Post-Exit Data Collection and Reporting, issued November 16, 2020 By April 16, 2021, BAs will be required to submit to SSO verification (template provided by SSO) signed by all VR staff, as applicable, that they have read and understand these policies and are committed to uphold the requirements in these policies. 3. SSO staff will issue ?HDVR Case File Document Checklist? and instructions in March 2021 to ensure that reportable individuals and participants of the vocational rehabilitation program have a case service record that is complete and conforms to the timeliness and documentation requirements per DVR?s internal control/quality assurance/future audit purposes and RSA?s compliance requirements. The Case File Documents Checklist is a tool designed to ensure case file documentation is accounted for upon case closure. A working copy of the Case File Documents Checklist is to be maintained in the hard copy case file and uploaded into Akamai-Aware only at time of closure and labeled accordingly. 4. SSO will finalize updates to referral and application procedures by July 2021 to include internal controls that reinforce effective practices and ensure state-wide standardization of the referral and application process, upload and filing of required documentation, and implementing checks and balances to avoid discrepancies in dates found on hard copy documents and Akamai-Aware system of record. All BAs will be required to review the procedures with staff after they are finalized and submit to SSO (template provided by SSO) verification signed by all VR staff, as applicable, that they have reviewed and understand the eligibility determination procedures. Training and/or review may be provided by SSO trainer and SSO subject matter expert (SME) if it is found necessary after Branches have had the opportunity to review published procedures. Frequently Asked Questions (FAQ) document will be maintained by SSO staff and made available to all staff on an on-going basis. 5. SSO will finalize updates to eligibility determination procedures by Fall 2021 to include internal controls that reinforce effective practices and ensure state-wide standardization of timely eligibility determinations within 60 days from the date of application, proper evaluation and implementation of extensions, and/or trial work experience (TWE) as needed and implementing checks and balances to avoid discrepancies in dates found on hard copy documents and Akamai-Aware system of record. All BAs will be required to review the procedures with staff after they are finalized and submit to SSO (template provided by SSO) verification signed by all VR staff, as applicable, that they have reviewed and understand the eligibility determination procedures. Training and/or review may be provided by SSO trainer and SSO subject matter expert (SME) if it is found necessary after Branches have had the opportunity to review published procedures. FAQ document will be maintained by SSO staff and made available to all staff on an on-going basis. 6. DVR/SSO will finalize updates to IPE development procedures by Spring 2022 to include internal controls that reinforce effective practices and ensure state-wide standardization of timely IPE development within 90 days from the date of eligibility determination, proper evaluation and implementation of IPE extensions as needed and implementing checks and balances to avoid discrepancies in dates found on hard copy documents and Akamai-Aware system of record. All BAs will be required to review the procedures with staff after they are finalized and submit to SSO (template provided by SSO) verification signed by all VR staff, as applicable, that they have reviewed and understand the eligibility determination procedures. Training and/or review may be provided by SSO trainer and SSO subject matter expert (SME) if it is found necessary after Branches have had the opportunity to review published procedures. FAQ document will be maintained by SSO staff and made available to all staff on an on-going basis. 7. VR is working with San Diego State University to complete training for eligibility determination and IPE development by the end of calendar year 2021 and implementation of training modules for provision of all VR services. Estimated completion date December 2022. 8. All BAs and/or supervisors will utilize the Activity Due Reports to check timely application input, eligibility determination, and IPE development and report their branch status to VRA on a monthly basis. 9. All BAs and/or supervisors will continue to conduct 5 audits monthly on active VR cases and record in DVR sharepoint site under each branch?s applicable folder located at: DHS DVR-Resources>Documents>CASE REVIEW>MONTHLY BRANCH CASE REVIEWS for VRA, VRAA and SSO review. Reviews at the Branch level will include the following but is not limited to reviewing of all eligibility determination documentation within the 60-day eligibility determination period (or during the extended eligibility waiver period of determination), all IPEs meet 90-day development and meet all prescribed requirements according to policy, review of purchases and services provided, review of employment placement, review of proper supporting documentation and that dates align with Akamai-Aware dates, and review of case notes thoroughly documenting the services provided for sustained compliance with policy and internal controls. 10. BAs and/or supervisors will review all case closures utilizing Case Closure checklist to evaluate all case closures and confirm timeliness, supporting documentation including but not limited to application, eligibility determination, IPE development, evaluation documents for competitive integrated employment, employment start date, employment at closure, etc. and status and appropriateness of the closure. Signed case closure checklist will be uploaded into Akamai-Aware, labeled appropriately, and filed in hard copy case file upon approval of closure. 11. DVR will utilize support staff to: a. Schedule appointments with clients and, if appropriate, to provide updates on the progress of the eligibility determination process with the client. b. Administrative support staff will be provided a monthly list of SSI/SSDI recipients. Assist the division in determining presumptive eligibility by utilizing regularly provided list of SSI/SSDI recipients. c. Scan and upload supporting documentation in the participant?s case record as requested by supervisor and/or VRS. 12. DVR will enforce monthly case reviews by supervisors of open and closed cases by participant ID, case master ID, case type, and review date in a centrally verifiable folder for compliance and monitoring at SSO. In addition, the casereview instrument will be updated to reflect Supported Employment, Service-E, Potentially Eligible and the use of comparable benefits monitoring. SSO staff will conduct random audits monthly and maintain verification in DHS DVR-Resources>Documents>CASE REVIEW>MONTHLY BRANCH CASE REVIEWS Training may be conducted by SSO SME as necessary depending on audit findings. 13. Compliance with DVR?s internal controls for eligibility determination will be added to VRS and Supervisor?s annual performance expectations and reviewed quarterly by their supervisor with supervisory discussion notes reflecting compliance or non-compliance for all referenced staff. Expected Completion Date: April 2022 Responding Officials: Maureen Bates, VR Administrator and Iva Cain, VR Assistant Administrator
2019-006
No on-site reviews were conducted during the year. Context: The Department has a total of 12 subrecipients, none of which received an on-site review. Cause: Management indicated that prior to March 2020, on-site reviews were not performed due to staffing shortages. Management further indicated that subsequent to March 2020, on-site reviews were not performed due to the restriction on travel due to COVID-19. Effect: Failure to perform the required on-site reviews resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-007. Recommendations: We recommend that the Department perform the annual on-site review as required by their policy or consider revising their policy to include an annual risk assessment of subrecipients to determine the appropriate level of subrecipient monitoring. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-007 Subrecipient Monitoring Federal Agency: U.S. Department of Agriculture CFDA No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance Program Cluster Requirement: Subrecipient Monitoring Type of Finding: Non-Compliance and Material Weakness Federal award no. 7HI400HI4 2018 ? 2020 and year: 7HI430HI4 2018 ? 2020 7HI430HI5 2019 ? 2021 Criteria: 2 CFR 200.332(b) requires the pass-thru entity to evaluate each subrecipient?s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring related to the subaward. 2 CFR 200.332(d) requires that the pass-thru entity monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward. In lieu of conducting a risk assessment as required by 2 CFR 200.332(b), the Department has adopted a policy to perform an annual audit for all subrecipients which includes a requirement for on-site reviews. Condition: No on-site reviews were conducted during the year. Context: The Department has a total of 12 subrecipients, none of which received an on-site review. Cause: Management indicated that prior to March 2020, on-site reviews were not performed due to staffing shortages. Management further indicated that subsequent to March 2020, on-site reviews were not performed due to the restriction on travel due to COVID-19. Effect: Failure to perform the required on-site reviews resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-007. Recommendations: We recommend that the Department perform the annual on-site review as required by their policy or consider revising their policy to include an annual risk assessment of subrecipients to determine the appropriate level of subrecipient monitoring. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
View of responsible official: The Department agrees with the finding and corrective action will be implemented. Corrective Action Taken or Planned: On-site reviews will be conducted beginning March 15, 2021. Review will include monitoring of activities to ensure funds are used for authorized purposes and in compliance with federal statutes, regulations, and the terms and conditions of the subaward. Review will also include verification that performance goals are achieved and that financial and performance reports are available. Expected Completion Date: September 30, 2021 Responding Official: Manuel Banasihan, BESSD SNAP Administrator (TA)
2019-007
The Department did not perform the required daily reconciliations. Context: The Department did not begin performing the required daily reconciliations until February 2020. Additionally, once daily reconciliations commenced, identified variances were not investigated and there was no review performed of the daily reconciliations. Cause: The Department noted there were no written procedures when the previous accountant responsible for the daily EBT reconciliations exited the Department in fiscal year 2019. Consequently, the Department had difficulty developing procedures to perform the required reconciliations. Also, the supervisor who performs the review of the reconciliation retired from the Department in December of 2019. Effect: Failure to perform the required reconciliations resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit 2019-008. Recommendations: We recommend that the Department develop procedures to ensure the daily reconciliation is completed, identified variances are resolved and the reconciliation is reviewed in a timely manner. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-008 EBT Reconciliation Federal Agency: U.S. Department of Agriculture CFDA No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance (SNAP) Cluster Requirement: Special Tests and Provisions ? EBT Reconciliation Type of Finding: Non-Compliance and Material Weakness Federal award no. 7HI400HI4 2018 ? 2020 and year: 7HI430HI4 2018 ? 2020 7HI430HI5 2019 ? 2021 Criteria: 7 CFR 274.4(a) requires that the Department perform daily reconciliations of all SNAP transactions between the State's Benefit Account, the US Treasury Department, and the EBT contractors. Condition: The Department did not perform the required daily reconciliations. Context: The Department did not begin performing the required daily reconciliations until February 2020. Additionally, once daily reconciliations commenced, identified variances were not investigated and there was no review performed of the daily reconciliations. Cause: The Department noted there were no written procedures when the previous accountant responsible for the daily EBT reconciliations exited the Department in fiscal year 2019. Consequently, the Department had difficulty developing procedures to perform the required reconciliations. Also, the supervisor who performs the review of the reconciliation retired from the Department in December of 2019. Effect: Failure to perform the required reconciliations resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit 2019-008. Recommendations: We recommend that the Department develop procedures to ensure the daily reconciliation is completed, identified variances are resolved and the reconciliation is reviewed in a timely manner. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Views of responsible officials: We concur with the findings of the audit. We were notified of the corrective actions that needed to take place at the end of the fiscal year 2019 audit. The daily EBT reconciliation started to take place immediately after. Corrective Action Taken or Planned: We are currently in the process of creating additional reports that will breakdown the daily issuances by individuals. This will help us identify any variances that may show up when doing the daily reconciliation. The daily reconciliations will be reviewed by a supervisor to ensure completeness and that it was done in a timely manner. We will continue to do the EBT reconciliation on a daily basis. Written procedures will be created in the case that there is a transition of duties or personnel. Completion Date: As soon as the reports are created, we will look at the variances within the reconciliation. Responding Officials: Joey Wong, FMO Accountant
2019-008
Unissued EBT cards were not properly secured at 2 processing centers. Context: We selected a non-statistical sample of 4 processing centers out of the Department?s 21 processing centers and noted that at 2 processing centers the unissued EBT cards that were not in use were not locked up. Cause: Although the Department has policies and procedures in place requiring unissued EBT cards to be locked up, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit 2019-009. Recommendations: We recommend the Department follow their policy to secure unissued EBT cards. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-009 EBT Card Security Federal Agency: U.S. Department of Agriculture CFDA No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance Program Cluster Requirement: Special Tests and Provisions ? EBT Card Security Type of Finding: Non-Compliance and Material Weakness Federal award no. 7HI400HI4 2018 ? 2020 and year: 7HI430HI4 2018 ? 2020 7HI430HI5 2019 ? 2021 Criteria: 7 CFR 274.8(b)(3) requires the Department to ensure there are storage and control measures to control blank unissued electronic benefit transfer (EBT) cards. To address this requirement, the Department has adopted a policy that requires each of its processing centers to lock up all unissued EBT cards when the cards are not in use. Condition: Unissued EBT cards were not properly secured at 2 processing centers. Context: We selected a non-statistical sample of 4 processing centers out of the Department?s 21 processing centers and noted that at 2 processing centers the unissued EBT cards that were not in use were not locked up. Cause: Although the Department has policies and procedures in place requiring unissued EBT cards to be locked up, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit 2019-009. Recommendations: We recommend the Department follow their policy to secure unissued EBT cards. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
View of responsible official: The Department agrees with the finding and have already implemented corrective action. Corrective Action Taken or Planned: EBT Project Manager, Sabrina Young, has reviewed the EBT Card Security Policy and Procedures with each of the two Section Administrators who directly oversee each of the two units that were cited for not having the unissued EBT cards locked up. Each of these two Section Administrators then reviewed the policy and procedures with the unit Supervisors and reminded them to enforce the EBT card security policy and procedures at all times. Please see response from each unit Supervisor: Response from unit Supervisor, Marci Baker, of the Wahiawa Processing Center (PC): On February 8th, Ms. Baker reviewed the policy and findings with both clerical at the Wahiawa PC. Since this is the second occurrence of the same finding in a two-year period, she stressed the importance of maintaining card security at all times. The following directive has been issued: Between any card issuances, the EBT card drawer will remain locked. Further, Ms. Baker will be conducting periodic checks on the drawer security and maintaining a log of these checks. In the event that there are issues, Ms. Baker will have a follow-up conversation with the clerical to reiterate the directive. Response from unit Supervisor, Raylene Sumimoto, of the OR&L Processing Center: Since the Spring of 2020, the supervisors and clerical staff at OR&L have been diligent in safeguarding the cards. An Office Assistant (OA) IV, Linda, has been primarily responsible for the bulk inventory of blank cards. She breaks it up into packs of 25 cards. Only a pack of 25 cards is taken out at a time and the rest are locked in the filing cabinet. That pack of 25 cards goes to another OA IV, Darrah, who keeps them secured at her desk. Supervisors also check the vertical filing cabinet throughout the day where the cards are kept to ensure that the lock is pushed in indicating that it is locked. To limit the number of staff handling the EBT cards, Linda and the other OAs issue only EBT cards through the system. Only one OA, mainly Darrah, at a time has access and issue card from the daily inventory. When Darrah leaves her desk, she locks it and brings the key with her at all times. The EBT Project Manager, Sabrina Young, also reviewed the EBT Card security policy and procedures with the Branch Administrator and Assistant Branch Administrator who reminded all units to follow the policies and procedures that are in place for EBT card security. Completion Date: February 2021 Responding Official: Sabrina Young, BESSD EBT Project Manager
2019-009
Eligibility determinations for 38 participants were not supported by the Department?s records or were not completed in accordance with the State Plan, which encompasses the regulations above. Context: We selected a non-statistical sample of 60 case files which approximated $22,000 in payments, out of a population of approximately 500 cases which approximated $3 million in payments, for testing and noted exceptions in 38 case files as follows: ? 24 case files where the executed Agreement was not updated to reflect the revised monthly assistance amount. ? 4 case files where the DOC was missing or did not support the amount paid. ? 6 case files where the eligibility supporting documents such as birth certificate, court order, consent form and 6 months of foster care eligibility were missing in the case files. ? 14 case files where the state, FBI, and/or child abuse and neglect clearances were missing in the case files. Cause: Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements and resulted in questioned costs. Questioned Costs: $14,128 Identification of a repeat finding: N/A Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-010 Maintaining Proper Case Documentation to Support Eligibility Determinations Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.090 Program: Guardianship Assistance Requirement: Eligibility, Activities Allowed or Unallowed, Allowable Cost Type of Finding: Non-Compliance and Material Weakness Federal award no. 1901HIGARD 2019 and year: 2001HIGARD 2020 Criteria: Pursuant to 42 USC 673(d)(1), an executed kinship guardianship assistance agreement with the prospective relative guardian must include the amount of and any adjustments based on the needs of the child. The "Guardianship/Permanency Assistance Agreement? (Agreement) is the agreement executed with the relative guardian. The Agreement outlines the terms and conditions for the participants and the Department, and includes the total amount of assistance payments. The Agreement may be further supplemented due to difficulties in caring for a child as determined by a caseworker on an as needed basis and documented on the ?Difficulty of Care? (DOC) worksheet. In the event of an increase or decrease to the amount of the assistance payments, the caseworkers are required to execute a revised Agreement. Pursuant to 42 USC 673(d)(3)(A), a child is eligible when the state agency determines the following: a) With respect to a child who has attained 14 years of age, the child has been consulted regarding the kinship guardianship arrangement. b) Eligible for foster care maintenance payments under 42 USC 672 while residing for at least six consecutive months in the home of the prospective relative guardian. c) Removed from his or her home pursuant to a voluntary placement agreement or as a result of a judicial determination to the effect that continuation in the home would be contrary to the welfare of the child. Pursuant to 42 USC 673(a)(4)(A), assistance payments must stop for a child who has attained 18 years of age or greater or 21 years of age if the State determines that the child has a mental or physical handicap. Pursuant to 42 USC 671(a)(20)(c), any relative guardian must satisfactorily have met a criminal records check, including a fingerprint-based check of national crime information databases (as defined in 28 USC 534(e)(3)(A)), and for checks described in 42 USC 671(a)(20)(B) on any relative guardian and any other adult living in the home of any relative guardian, before the relative guardian may receive kinship guardianship assistance payments on behalf of the child. Condition: Eligibility determinations for 38 participants were not supported by the Department?s records or were not completed in accordance with the State Plan, which encompasses the regulations above. Context: We selected a non-statistical sample of 60 case files which approximated $22,000 in payments, out of a population of approximately 500 cases which approximated $3 million in payments, for testing and noted exceptions in 38 case files as follows: ? 24 case files where the executed Agreement was not updated to reflect the revised monthly assistance amount. ? 4 case files where the DOC was missing or did not support the amount paid. ? 6 case files where the eligibility supporting documents such as birth certificate, court order, consent form and 6 months of foster care eligibility were missing in the case files. ? 14 case files where the state, FBI, and/or child abuse and neglect clearances were missing in the case files. Cause: Although the Department has established policies and procedures in place over the application process and determination of assistance amount, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements and resulted in questioned costs. Questioned Costs: $14,128 Identification of a repeat finding: N/A Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Our plans to reduce and/or eliminate these errors will include: 1. Training of all Social Service Assistant staff about what needs to be filed in the case file using the Permanency Assistance Checklist, and the following: CWS staff shall double-check that the amount of the guardianship payment and the amount of the Difficulty of Care (DOC) payment, if applicable, match the amount on the Agreement and DOC worksheet, and in the Child Protective Services System (CPSS): a. Ensure eligibility supporting documents (including the child?s birth certificate, court order, consent form and 6 months of foster board IV-E eligibility) are present in the case record. b. Supervisors shall review the forms and confirm that the amounts match, then authorize payments in CPSS. c. Child Welfare Services Branch (CWSB) shall monitor and conduct monthly, random reviews of a minimum of twenty IV-E guardianship assistance payment cases per Section: i. Staff from the Specialized Workload Assessment Team (SWAT) will be utilized monthly to review cases from statewide sections to ensure documents are present in case records ii. If there are discrepancies in the amounts, staff will correct the amounts and enter the corrected amounts into CPSS. iii. If the Agreements do not contain the correct amount, staff will contact the guardian and explain what the correct amount should be and obtain the signature of the guardian(s) on the amended Agreement. Findings will be shared with the assigned Section Administrator and Child Welfare Services Branch Administrator (CWSBA) for inclusion in individual staff/supervisor meetings. 2. Training of Licensing staff to ensure all state, FBI, and/or child abuse and neglect clearances are included in the licensing files with the following: a. Certify all clearances are valid. If no valid clearance on record, staff shall conduct clearances immediately of those that have expired. Note: CWSB is in the process of modernizing the resource home licensing data base. This will allow for documents in licensing files to be uploaded to a website for easier access and monitoring/tracking of document completion and record placement. 3. Regular reminders and follow-up discussions shall occur with all staff responsible for case files content, through individual monthly supervision and retraining as necessary, emphasizing diligence in ensuring that all forms are properly signed and present in case files. Expected Completion Date: June 30, 2022 Responding Official: Bernadette Lane, SSD Assistant Program Administrator
3 participants where the support to show income information was requested through IEVS in accordance with the Department?s policies and procedures was not maintained. Context: We selected a non-statistical sample of 60 case files for testing and noted 3 instances where the Department?s records did not support the use of the income information obtained through IEVS to re-evaluate the initial benefit calculations. Cause: Program management indicated that there are policies and procedures in place regarding the use of the IEVS and the retention of the required documentation but these policies and procedures were not consistently followed. Effect: Failure to properly document use of the IEVS to evaluate benefit amounts resulted in potential over payments of benefits. Questioned costs: $1,863 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-011. Recommendation: The Department should be more diligent in consistently following its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-011 Income Eligibility and Verification System Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.558 Program: Temporary Assistance for Needy Families Cluster Requirement: Special Test ? Income Eligibility and Verification System Type of Finding: Non-Compliance and Material Weakness Federal award no. G1501HITANF 2015 and year: G1801HITANF 2018 G1901HITANF 2019 G2001HITANF 2020 Criteria: Title 45 CFR 205.55, requires the State agency to request through the Income Eligibility and Verification System (IEVS), wage information, unemployment compensation, social security income, unearned income, and any other income information. Condition: 3 participants where the support to show income information was requested through IEVS in accordance with the Department?s policies and procedures was not maintained. Context: We selected a non-statistical sample of 60 case files for testing and noted 3 instances where the Department?s records did not support the use of the income information obtained through IEVS to re-evaluate the initial benefit calculations. Cause: Program management indicated that there are policies and procedures in place regarding the use of the IEVS and the retention of the required documentation but these policies and procedures were not consistently followed. Effect: Failure to properly document use of the IEVS to evaluate benefit amounts resulted in potential over payments of benefits. Questioned costs: $1,863 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-011. Recommendation: The Department should be more diligent in consistently following its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Financial Assistance Program (FAP) will work with the Staff Development Office and Statewide Branch Administrator to ensure that all Eligibility Workers are trained and reminded how to properly access, review, take appropriate and timely action, document findings, and secure IEVS data and reports. The FAP and SNAP offices will also issue an annual Policy Clarification on reviewing and safe-handling procedures of IEVS data and reports. Expected Completion Date: On-going Responding Official: Elisa Furtado-Fische, BESSD Program Specialist
2019-011
There were 4 participant files where appropriate action was not taken to comply with the requirements. Context: We selected a non-statistical sample of 9 participant files for testing out of a population of 44 participant files that were determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. During our review, we noted 4 participant files did not contain any correspondence, notices, or documentation to indicate any follow up action, up to and including case closure and cessation of benefits, were performed. Consequently, there may be potential overpayments of benefits of $28,244. Cause: There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Effect: Failure to take appropriate action resulted in non-compliance with the requirements and questioned costs. Questioned Costs: $28,244 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-012. Recommendations: We recommend that the Department diligently perform the required procedures and to develop system controls to suspend benefits until non-cooperation is addressed. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-012 Maintaining Proper Case Documentation to Support Compliance with Child Support Non-Cooperation Requirement Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.558 Program: Temporary Assistance for Needy Families Cluster Requirement: Special Tests and Provisions - Child Support Non-Cooperation Type of Finding: Non-Compliance and Material Weakness Federal award no. G1501HITANF 2015 and year: G1801HITANF 2018 G1901HITANF 2019 G2001HITANF 2020 Criteria: 45 CFR section 264.30 states the Title IV-A agency must take appropriate action, as defined, if the Title IV-D agency determines that an individual is not cooperating with the child support enforcement requirements. Condition: There were 4 participant files where appropriate action was not taken to comply with the requirements. Context: We selected a non-statistical sample of 9 participant files for testing out of a population of 44 participant files that were determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. During our review, we noted 4 participant files did not contain any correspondence, notices, or documentation to indicate any follow up action, up to and including case closure and cessation of benefits, were performed. Consequently, there may be potential overpayments of benefits of $28,244. Cause: There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Effect: Failure to take appropriate action resulted in non-compliance with the requirements and questioned costs. Questioned Costs: $28,244 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-012. Recommendations: We recommend that the Department diligently perform the required procedures and to develop system controls to suspend benefits until non-cooperation is addressed. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department is currently building a new system which will incorporate non-compliance notification from the CSEA. The system will de-authorize the TANF payment and issue appropriate closure notice which will include what steps the client has to take to resolve the non-compliance issue. The new system should be rolled out by the latter half of 2021 and hopefully this will resolve this issue. Until the new system rollout, the program office will stress training and documentation. Expected Completion Date: On-going Responding Official: Cheryl Chang, BESSD Eligibility Program Specialist
2019-012
Eligibility determinations for 2 participants were not properly supported by the Department?s records or were not completed in accordance with the State Plan. Context: We selected a non-statistical sample of 60 participant files, representing approximately $34,000 of benefit payments, out of a population of approximately 7,000 cases, representing approximately $15,000,000 of benefit payments, for testing and noted exceptions in 2 case files where the form DHS 1006, which documents the caseworker interview was not maintained, resulting in potential benefit overpayments of $562. Cause: Although the Department has established policies and procedures in place over the application process, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements, and resulted in questioned costs. Questioned Costs: $562 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-010. Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-013 Maintaining Proper Case Documentation to Support Eligibility Determinations Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.558 Program: Temporary Assistance for Needy Families Cluster Requirement: Eligibility Type of Finding: Known Questioned Costs When Likely Questioned Costs Are Greater Than $25,000 Federal award no. G1501HITANF 2015 and year: G1801HITANF 2018 G1901HITANF 2019 G2001HITANF 2020 Criteria: The State of Hawaii Temporary Assistance for Needy Families State Plan (State Plan) provides the rules and regulations for the eligibility requirements of the TANF program subject to the requirements of 45 CFR 206.10. To apply for assistance, applicants must complete and file an application form, be interviewed by a caseworker, and have certain information verified. Condition: Eligibility determinations for 2 participants were not properly supported by the Department?s records or were not completed in accordance with the State Plan. Context: We selected a non-statistical sample of 60 participant files, representing approximately $34,000 of benefit payments, out of a population of approximately 7,000 cases, representing approximately $15,000,000 of benefit payments, for testing and noted exceptions in 2 case files where the form DHS 1006, which documents the caseworker interview was not maintained, resulting in potential benefit overpayments of $562. Cause: Although the Department has established policies and procedures in place over the application process, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements, and resulted in questioned costs. Questioned Costs: $562 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2019-010. Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department will begin to have team leaders review cases for completeness and documentation to support eligibility determination. Training should emphasize the importance of case documentation. Documents should be promptly filed in the electronic case file. Team leaders, Branch administrators, and the training office will be reminded to inform staff of the importance of the eligibility worker documenting and filing documents used in eligibility determination. Expected Completion Date: On-going Responding Official: Cheryl Chang, BESSD Eligibility Program Specialist
2019-010
There was 1 participant file where a required form, the DHS 1100B, was not maintained to support eligibility determination. Context: We selected a non-statistical sample of 60 participant files, representing approximately $98,000 of benefit payments, out of a population of approximately 2,700 participants, representing approximately $13,129,000 of benefit payments for testing and noted 1 case file where the form DHS 1100B was missing. Cause: Although the Department has policies and procedures in place to ensure the proper support for eligibility determinations are maintained in a participants file, there was a lack of diligence in complying with the policies and procedures. Effect: 1 participant that was determined to be eligible did not have the proper support for eligibility determination. Questioned Costs: $1,955 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-009. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2020-014 Maintaining Proper Case Documentation to Support Eligibility Determination Federal Agency: U.S Department of the Interior CFDA No.: 15.875 Program: Economic, Social, and Political Development of the Territories Requirement: Eligibility Type of Finding: Known Questioned Costs When Likely Questioned Costs Are Greater Than $25,000 Federal award no. Hawaii-CI-2019-1 2019 and year: Criteria: In accordance with 42 CFR 435.907, the DHS must accept an application from the applicant, and any documentation required to establish eligibility. Condition: There was 1 participant file where a required form, the DHS 1100B, was not maintained to support eligibility determination. Context: We selected a non-statistical sample of 60 participant files, representing approximately $98,000 of benefit payments, out of a population of approximately 2,700 participants, representing approximately $13,129,000 of benefit payments for testing and noted 1 case file where the form DHS 1100B was missing. Cause: Although the Department has policies and procedures in place to ensure the proper support for eligibility determinations are maintained in a participants file, there was a lack of diligence in complying with the policies and procedures. Effect: 1 participant that was determined to be eligible did not have the proper support for eligibility determination. Questioned Costs: $1,955 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-009. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Part VI Correction Action Plan.
View of responsible official: The Department agrees with the specific finding of this case and will implement corrective action. Corrective Action Taken or Planned: Med-QUEST Eligibility Branch Administrator will reissue the relevant Program and Policy Directive and reinforce document retention to properly support determinations. Expected Completion Date: April 1, 2021 Responding Official: Lori Lei Aponte, MQD Eligibility Branch Administrator (TA)
FAC accepted this audit on March 15, 2020 — management decision was due September 15, 2020.
Eligibility determinations for both MAGI and MAGI-excepted applications were not processed in accordance with the time standards. Context: We obtained the CMS Performance Metrics Report and noted that there were approximately 51,000 applications received during fiscal year 2019. At the end of each month, there was an average of approximately 90 MAGI applications and approximately 10 MAGI excepted applications for which eligibility was not determined in a timely manner. Additionally, there were approximately 332,000 renewals processed during fiscal year 2019. At the end of each month, there was an average of approximately 4,300 cases whose annual re verification was not completed within 12 months. Cause: The Department has identified issues in the system logic used in producing the CMS Performance Metric report for re-verifications. For the MAGI and MAGI-excepted initial applications, the cause is a lack of diligence in complying with the Department?s policies and procedures. Effect: There was an average of approximately 90 Modified Adjusted Gross Income (MAGI) applications and 7 MAGI excepted applications for which eligibility was not determined in a timely manner. Also there were approximately 4,300 cases whose annual re verification was not completed within 12 months. Questioned costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-002. Recommendations: We recommend the Department review the system logic utilized in producing the CMS Performance Metrics report to ensure the information is aggregated properly for re-verification and be more diligent in complying with policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-002 Complete Eligibility Applications and Annual Eligibility Re-Verifications in a Timely Manner Federal Agency: U.S Department of Health and Human Services CFDA No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. 05-1805HI5028 2018 and year: 05-1905HI5028 2019 Criteria: Title 42 CFR Part 435.911 requires the timely determination of eligibility of individuals who apply for Medicaid benefits within 1) ninety days for applicants who apply for Medicaid on the basis of disability (MAGI-excepted), and 2) forty five days for all other applicants (MAGI). In addition, Title 42 CFR Part 435.916 requires annual re-verifications of participant eligibility. Condition: Eligibility determinations for both MAGI and MAGI-excepted applications were not processed in accordance with the time standards. Context: We obtained the CMS Performance Metrics Report and noted that there were approximately 51,000 applications received during fiscal year 2019. At the end of each month, there was an average of approximately 90 MAGI applications and approximately 10 MAGI excepted applications for which eligibility was not determined in a timely manner. Additionally, there were approximately 332,000 renewals processed during fiscal year 2019. At the end of each month, there was an average of approximately 4,300 cases whose annual re verification was not completed within 12 months. Cause: The Department has identified issues in the system logic used in producing the CMS Performance Metric report for re-verifications. For the MAGI and MAGI-excepted initial applications, the cause is a lack of diligence in complying with the Department?s policies and procedures. Effect: There was an average of approximately 90 Modified Adjusted Gross Income (MAGI) applications and 7 MAGI excepted applications for which eligibility was not determined in a timely manner. Also there were approximately 4,300 cases whose annual re verification was not completed within 12 months. Questioned costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-002. Recommendations: We recommend the Department review the system logic utilized in producing the CMS Performance Metrics report to ensure the information is aggregated properly for re-verification and be more diligent in complying with policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: With respect to timely eligibility determinations of initial applications, the Department acknowledges that of the 0.20% applications determined untimely, some may be exempt from the timeliness standard. For those that aren?t exempt, we will work with staff to ensure eligibility determinations are completed in a timely manner. With respect to timely annual renewals, the Department is actively engaged in the implementation of business process improvements to ensure that staff update eligibility renewal dates when re-determining eligibility at annual renewal. Incorrect eligibility renewal dates may be inflating the numbers for redeterminations not completed timely. The Department has also identified that the system is not updating renewal dates when re-determining eligibility at annual renewal and is planning a system modification to address the issue. Expected Completion Date: December 31, 2020 Responding Official: Emerald Adams, MQD KOLEA Project Manager
2018-002
Eligibility determinations for 4 participants was not supported by the Department?s records. Context: During our audit, we selected a non statistical sample of 60 participants for testing and noted the following: ? 1 case file where the Supplemental Form for Individuals Applying for Coverage on the basis of Age, Blindness or Disability (DHS 1100B) was not maintained. ? 1 case file where the documentation to support the participant?s date of birth was not maintained. ? 2 case files where the eligibility factors such as date of birth, social security number, and citizenship was not verified in a timely manner. Cause: Although the Department has policies and procedures in place to ensure the proper eligibility documents are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: 4 participants received benefits in excess of the amounts supported by the Department?s documentation. Questioned Costs: $5,693 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-003. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-003 Maintaining Proper Case Documentation to Support Eligibility Determinations Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. 05-1805HI5028 2018 and year: 05-1905HI5028 2019 Criteria: Per 42 CFR 431.17(b), "A State plan must provide that the Medicaid agency will maintain or supervise the maintenance of the records necessary for the proper and efficient operation of the plan. The records must include individual records on each applicant and recipient that contain information on facts essential to determination of initial and continuing eligibility." For aged, blind, or disable (MAGI-excepted) individuals, verification of assets is required per 42 CFR 435.840. Condition: Eligibility determinations for 4 participants was not supported by the Department?s records. Context: During our audit, we selected a non statistical sample of 60 participants for testing and noted the following: ? 1 case file where the Supplemental Form for Individuals Applying for Coverage on the basis of Age, Blindness or Disability (DHS 1100B) was not maintained. ? 1 case file where the documentation to support the participant?s date of birth was not maintained. ? 2 case files where the eligibility factors such as date of birth, social security number, and citizenship was not verified in a timely manner. Cause: Although the Department has policies and procedures in place to ensure the proper eligibility documents are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: 4 participants received benefits in excess of the amounts supported by the Department?s documentation. Questioned Costs: $5,693 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-003. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department is currently undergoing a business process transformation intended to establish, train, and maintain consistent and efficient processes to ensure compliance with the Federal requirements. Expected Completion Date: On-going Responding Official: Emerald Adams, MQD KOLEA Project Manager
2018-003
Required screening and enrollment for 8 providers were not properly supported by the Department?s records and the Medicaid Application/Change Request Form (DHS 1139) were not maintained. Also on-site inspections were not performed for 4 providers. Context: We selected 60 providers for testing which approximated $555,000 payments out of a population of approximately 1,900 providers which approximated $116 million for testing and noted the following: ? 8 providers where the Medicaid Application/Change Request Form (DHS 1139), which documents the screening and required disclosures, were not maintained. ? 4 providers where on-site visit was not performed as required. Cause: Although the Department has policies and procedures in place to ensure the proper forms and documentation are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement resulting in potential questioned costs. Questioned costs: $48,009 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-004. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-004 Revalidation of Provider Eligibility Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.777 and 93.778 Program: Medicaid Cluster Requirement: Special Tests and Provisions - Provider Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. 05-1805HI5028 2018 and year: 05-1905HI5028 2019 Criteria: The State Medicaid Agency, Department of Human Services, Med Quest Division is required to screen and enroll providers in accordance with 42 CFR Part 455, subpart E and make certain disclosures to the State Medicaid Agency in accordance with 42 CFR Part 455, subpart B. Also pursuant to 42 CFR 455.432, the State Medicaid Agency must (a) conduct pre-enrollment site visits of providers who are designated as ?moderate? or ?high? categorical risks to the Medicaid program and (b) must require any enrolled provider to permit CMS, its agents, its designated contractors, or the State Medicaid Agency to conduct unannounced on-site inspections of any or all provider locations. Condition: Required screening and enrollment for 8 providers were not properly supported by the Department?s records and the Medicaid Application/Change Request Form (DHS 1139) were not maintained. Also on-site inspections were not performed for 4 providers. Context: We selected 60 providers for testing which approximated $555,000 payments out of a population of approximately 1,900 providers which approximated $116 million for testing and noted the following: ? 8 providers where the Medicaid Application/Change Request Form (DHS 1139), which documents the screening and required disclosures, were not maintained. ? 4 providers where on-site visit was not performed as required. Cause: Although the Department has policies and procedures in place to ensure the proper forms and documentation are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement resulting in potential questioned costs. Questioned costs: $48,009 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-004. Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department does not dispute the finding and will implement corrective action. Corrective Action Taken or Planned: We have shared with the auditors in the past that the Department has been short staffed in the Provider Enrollment section for the work in front of us -- ever since we were told by CMS in May of 2017 that the Department is required to screen ALL of our providers -- and this overwhelming body of work often required us to use any `available? staff to assist with various provider enrollment work that needs to be completed. This often requires on-the-job training by various personnel. This may have contributed to the lack of diligence in complying with the policies and procedures. In the past year, we have been successful in hiring one additional staff in the provider enrollment section and this has alleviated some of the workload burden. Secondly, we have had a solid working relationship with our new Provider Enrollment vendor, Koan. They have effectively helped us reduce our re-validation application backlog to near zero and are projected to continue on over the next few years as our Provider Enrollment vendor. Finally, we will be going live on March 2, 2020 with our new web-based provider enrollment system ? HOKU. As we stand up the HOKU system, we are developing an online library of policies and procedures that will be available to all staff and vendors working on provider enrollment. This will promote operational consistency and compliance for staff and vendors as providers are enrolled into the Medicaid program. Expected Completion Date: The HOKU system is scheduled to go-live on March 2, 2020. Our contingency plans leave open the possibility of this date being pushed back for various reasons however, our expectation is that the system will go-live no later than July 1, 2020. Responding Official: Jon Fujii, MQD Health Care Services Branch Administrator
2018-004
Program income amounts were not disbursed prior to requesting additional funds. Context: During our audit, we noted approximately $454,000 of program income was received throughout the year and, although requests for additional funds were made throughout the year, the Department maintained a program income balance of approximately $434,000 at June 30, 2019. Cause: The program does not have documented policies and procedures over program income that address the roles and responsibilities of program personnel. Effect: Failure to disburse program income before requesting additional funds resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend the Department develop written policies and procedures over program income and diligently follow them to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-005 Program Income Federal Agency: U.S. Department of Education CFDA No.: 84.126 Program: Rehabilitation Services - Vocational Rehabilitation Grants to States Requirement: Program Income Type of Finding: Non-Compliance and Material Weakness Federal award no. H126A170015 2017 and year: H126A180015 2018 H126A190015 2019 Criteria: 34 CFR 361.63 requires the State to disburse program income funds before requesting additional funds from the Department of Education. Condition: Program income amounts were not disbursed prior to requesting additional funds. Context: During our audit, we noted approximately $454,000 of program income was received throughout the year and, although requests for additional funds were made throughout the year, the Department maintained a program income balance of approximately $434,000 at June 30, 2019. Cause: The program does not have documented policies and procedures over program income that address the roles and responsibilities of program personnel. Effect: Failure to disburse program income before requesting additional funds resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend the Department develop written policies and procedures over program income and diligently follow them to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Views of responsible officials: The Department agrees with the finding and corrective action is planned and will be implemented. Corrective Action Taken or Planned: To be implemented and executed by May 30, 2020: 1. By June 30, 2020, DVR will update internal controls to include clarification of written policies and procedures and roles and responsibilities of staff responsible for program income. 2. DVR will work with State Budget and Finance and DHS Fiscal Management Office for guidance on state policies associated with federal requirements for program income spending and period of performance. 3. DVR will work with Rehabilitation Services Administration (RSA) and/or WINTAC to obtain technical assistance with federal funder to ensure updates of internal controls for policies and procedures comply with federal and state regulations. 4. DVR will provide staff with training on federal and state rules for program income including but not limited to: 34 CFR 361.63, 2 CFR 200.80, 2 CFR 200.307, Randolph-Sheppard Program Income, and other applicable federal rules to provide guidance in conjunction with established state policies on the implementation of final updated internal controls, and on-going updates as applicable. 5. Copies of staff training logs will be maintained by DVR Staff Services Office for all staff, with training plans updated by June 30, 2020 to include program income internal controls as applicable. Expected Completion Date: August 31, 2020 Responding Officials: Maureen Bates, DVR Administrator and Iva Cain, DVR Assistant Administrator
40 cases did not have supporting documentation and/or there were discrepancies between the information per the case management system and the supporting documentation for one or more key data elements. Context: During our audit, we selected a non-statistical sample of 60 participant case files, out of a population of 8,167 based on the participants from two quarterly reports, for testing and noted the following: ? 10 selections tested did not have supporting documentation for one or more key data elements and had discrepancies between the dates per the case management system and per the supporting documentation for one or more key data elements. ? 16 selections tested did not have supporting documentation for one or more key data elements. ? 14 selections tested had discrepancies between the dates per the case management system and per the supporting documentation for one or more key data elements. Cause: Although the Department has policies and procedures in place to ensure that the supporting documents are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: 40 cases did not have supporting documentation and/or there were discrepancies in the information per the case management system and the supporting documentation for one or more key data elements. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-006 Maintaining Proper Case Documentation Federal Agency: U.S. Department of Education CFDA No.: 84.126 Program: Rehabilitation Services - Vocational Rehabilitation Grants to States Requirement: Reporting Type of Finding: Non-Compliance and Material Weakness Federal award no. H126A170015 2017 and year: H126A180015 2018 H126A190015 2019 Criteria: Rehabilitation Services Administration (RSA) Policy Directive RSA-PD-16-04 and 34 CFR 361.47 requires State Vocational Rehabilitation agencies to maintain supporting documentation (either hard copies or scanned copies) particularly regarding eligibility determinations, development of the individualized plan for employment, services provided, and case closure in the service record or case management system. Data reported in the case management system must match the supporting documentation for data elements containing critical information. Condition: 40 cases did not have supporting documentation and/or there were discrepancies between the information per the case management system and the supporting documentation for one or more key data elements. Context: During our audit, we selected a non-statistical sample of 60 participant case files, out of a population of 8,167 based on the participants from two quarterly reports, for testing and noted the following: ? 10 selections tested did not have supporting documentation for one or more key data elements and had discrepancies between the dates per the case management system and per the supporting documentation for one or more key data elements. ? 16 selections tested did not have supporting documentation for one or more key data elements. ? 14 selections tested had discrepancies between the dates per the case management system and per the supporting documentation for one or more key data elements. Cause: Although the Department has policies and procedures in place to ensure that the supporting documents are maintained, there was a lack of diligence in complying with the policies and procedures. Effect: 40 cases did not have supporting documentation and/or there were discrepancies in the information per the case management system and the supporting documentation for one or more key data elements. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend the Department be more diligent in following its existing policies and procedures to ensure compliance with the Federal requirements. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Views of responsible officials: The Department agrees with the finding and corrective action is planned and will be implemented. Corrective Action Taken or Planned: To be implemented and executed immediately: 1. DVR Branch Administrators, Supervisors, and Staff Services Office will coordinate mandatory training/re-training for all VRS Counselors and Staff Services Assistants on a quarterly basis beginning immediately with completion by June 30, 2021 on required documentation compliance, to include the following topics, and any additional topics identified during this training period, for sustained compliance with documentation requirements: a. Eligibility Determinations b. Development of Individualized Plan for Employment c. Proper documentation of services provided d. Case closures in the service record and case management system e. Review of AWARE ? AKAMAI System to ensure staff know how to properly capture data and ensure that data matches supporting documentation for data elements containing critical information 2. Complete training and review of Rehabilitation Services Administration (RSA) Policy Directive RSA-PD-16-04 as applicable to topics listed above in 1, a-d, by June 30, 2020. a. Review of US Department of Education (DOE) Office of Special Education and Rehabilitation Services (OSERS) Guidelines: Supporting Documentation for Case Service Report (RSA-911) 3. Complete training and review of 34 CFR 361.47, Record of Services, by June 30, 2020. 4. DVR will address discrepancies of dates and supporting documentation between the case management system and case file record by assigning the following responsibilities to DVR staff: a. Staff Services Office i. Provide additional guidance by way of checklists, cheat sheets, desk aids or updates/reminders to current case management tools for Branch Administrators, Supervisors, and Counselors ii. Update case review instruments iii. Monitor ?Activity Due? reports to ensure that timeframes are being met in accordance with Policy and Procedures iv. Quarterly case reviews of a random sampling to check that data in case management system match supporting documentation b. Branch Administrators i. Attend refresher trainings and be available to train staff as well as ensure understanding and execution of the proper case management protocols ii. Update Supervisor and VRS training plans and annual performance expectations to reflect compliance with documentation requirements, and implementation of training topics in item 1, a-e c. Supervisors/Branch Administrators (as applicable) i. Monitor case records prior to case status movement to ensure proper case documentation is compiled and matches data reported in case management system and meets established timelines ii. Use case review instruments to conduct monthly case reviews of open and closed cases by participant ID, case master ID, case type and review date iii. Report monthly on case reviews conducted, and identify needed corrections with timeline for completion, and follow up case review deadline d. Counselors i. Utilize case management tools to ensure all dates and documentation match in both case management system and case file record ii. Utilize ?Activity Due? reports and notifications iii. Use case file record checklists provided by SSO e. Support Staff i. Assist in uploading documentation and monitoring that support documentation are available and match with system dates and recorded activities ii. Assist in scheduling appointments within applicable timelines to meet the timelines for eligibility determination, development of the individualized plan for employment (IPE), and IPE updates Expected Completion Date: June 30, 2021 Responding Officials: Maureen Bates, VR Administrator and Iva Cain, VR Assistant Administrator
No on-site reviews were conducted during the year. Context: The Department has a total of 15 subrecipients, none of which received an on-site review. Cause: Management indicated that the on-site reviews were not performed due to staffing shortages. Effect: Failure to perform the required on-site reviews resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend that the Department perform the annual on-site review as required or consider revising their policy to include an annual risk assessment of subrecipients to determine the appropriate level of subrecipient monitoring. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-007 Subrecipient Monitoring Federal Agency: U.S. Department of Agriculture CFDA No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance Program Cluster Requirement: Subrecipient Monitoring Type of Finding: Non-Compliance and Material Weakness Federal award no. 7HI400HI4 2017 ? 2019 and year: 7HI430HI4 2017 ? 2019 7HI430HI5 2018 ? 2020 Criteria: 2 CFR 200.331(d) requires that the pass-through entity monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward. To address this requirement, the Department?s policy is to perform an annual audit for all subrecipients. The annual audit includes a requirement for on-site reviews. Condition: No on-site reviews were conducted during the year. Context: The Department has a total of 15 subrecipients, none of which received an on-site review. Cause: Management indicated that the on-site reviews were not performed due to staffing shortages. Effect: Failure to perform the required on-site reviews resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend that the Department perform the annual on-site review as required or consider revising their policy to include an annual risk assessment of subrecipients to determine the appropriate level of subrecipient monitoring. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department agrees with the finding and corrective action is planned and will be implemented. Corrective Action Taken or Planned: The SNAP office will have a staff member with subrecipient monitoring experience returning to the office at the end of February 2020 after being on a special assignment for the division. Subrecipient monitoring visits will then be planned for March 2020 and will be conducted by our returning staff member. For training purposes, we will have additional SNAP Program staff shadow the returning staff member on these visits to ensure annual on-site reviews are performed as required. We will also be revising our policies and procedures to include annual risk assessments of subrecipients to determine the appropriate level of subrecipient monitoring. Expected Completion Date: September 30, 2020 Responding Official: Scott Nakasone, BESSD Assistant Administrator
The Department did not perform the required daily reconciliations. Context: The Department indicated that they did not perform any of the daily reconciliations during the year. Cause: The previous accountant responsible for the daily EBT reconciliations exited the Department. In addition, the Department changed its EBT contractor and was unable to develop procedures in a timely manner to perform the required reconciliations. Effect: Failure to perform the required reconciliations resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend that the Department work with its EBT contractor to develop the necessary procedures in order to perform the required reconciliations. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-008 EBT Reconciliation Federal Agency: U.S. Department of Agriculture CFDA No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance Program Cluster Requirement: Special Tests and Provisions ? EBT Reconciliation Type of Finding: Non-Compliance and Material Weakness Federal award no. 7HI400HI4 2017 ? 2019 and year: 7HI430HI4 2017 ? 2019 7HI430HI5 2018 ? 2020 Criteria: 7 CFR 274.4(a) requires that the Department perform daily reconciliations of all SNAP transactions between the State's Benefit Account, the US Treasury Department, and the EBT contractors. Condition: The Department did not perform the required daily reconciliations. Context: The Department indicated that they did not perform any of the daily reconciliations during the year. Cause: The previous accountant responsible for the daily EBT reconciliations exited the Department. In addition, the Department changed its EBT contractor and was unable to develop procedures in a timely manner to perform the required reconciliations. Effect: Failure to perform the required reconciliations resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend that the Department work with its EBT contractor to develop the necessary procedures in order to perform the required reconciliations. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Views of responsible officials: The Department agrees with the finding and have implemented corrective action. Corrective Action Taken or Planned: At the time of the audit, Fiscal Management Office (FMO) was only reconciling on a monthly basis however since February 2020, FMO has begun doing daily EBT reconciliation of the ASAP and FIS report EBTDS408-1 ?Daily ASAP Balancing.? Policies and procedures are in place to ensure that the required reconciliations are done daily. Completion Date: February 2020 Responding Officials: Sabrina Young, BESSD EBT Project Manager and Joey Wong, FMO Accountant
Unissued EBT cards were not properly secured at 2 processing centers. Context: We selected a non-statistical sample of 4 processing centers out of the Department?s 21 processing centers and noted that at 2 processing centers the unissued EBT cards that were not in use were not locked up. Cause: Although the Department has policies and procedures in place requiring unissued EBT cards to be locked up, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend the Department follow their policy to secure unissued EBT cards. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-009 EBT Card Security Federal Agency: U.S. Department of Agriculture CFDA No.: 10.551 and 10.561 Program: Supplemental Nutrition and Assistance Program Cluster Requirement: Special Tests and Provisions ? EBT Card Security Type of Finding: Non-Compliance and Material Weakness Federal award no. 7HI400HI4 2017 ? 2019 and year: 7HI430HI4 2017 ? 2019 7HI430HI5 2018 ? 2020 Criteria: 7 CFR 274.8(b)(3) requires the Department to ensure there are storage and control measures to control blank unissued electronic benefit transfer (EBT) cards. To address this requirement, the Department has adopted a policy that requires each of its processing centers to lock up all unissued EBT cards when the cards are not in use. Condition: Unissued EBT cards were not properly secured at 2 processing centers. Context: We selected a non-statistical sample of 4 processing centers out of the Department?s 21 processing centers and noted that at 2 processing centers the unissued EBT cards that were not in use were not locked up. Cause: Although the Department has policies and procedures in place requiring unissued EBT cards to be locked up, there was a lack of diligence in complying with the policies and procedures. Effect: The Department was not in compliance with the requirement. Questioned Costs: None Identification of a repeat finding: N/A Recommendations: We recommend the Department follow their policy to secure unissued EBT cards. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department agrees with the finding and have implemented corrective action. Corrective Action Taken or Planned: The EBT Office has begun doing EBT Management Evaluation Reviews of the Processing Centers to ensure compliance with EBT Issuance, System Access, and Inventory Control & Management procedures and regulations. The EBT Office has completed Section One, which is the OR&L processing center and the KPT processing center. The EBT Office will be continuing with these EBT Management Evaluation Reviews of Section Two, Kauai Section, and Maui Section later this year. The EBT Office will complete the EBT Management Evaluation Reviews of all (20) twenty processing centers statewide by December 2022. The EBT Office will then continue these Management Evaluations on a rotational basis by completing two sections (one Oahu and one neighbor island) each year. Expected Completion Date: December 2022 Responding Official: Sabrina Young, BESSD EBT Project Manager
Eligibility determinations for 6 participants were not properly supported by the Department?s records or were not completed in accordance with the State Plan. Context: We selected a non-statistical sample of 60 participant files out of a population of approximately 7,000 cases for testing and noted exceptions in 6 case files as follows: ? 2 case files where the eligibility determination was completed outside of the required 45 day period. ? 1 case file where the benefit calculation was performed without using the current income information, resulting in potential benefit overpayments of $147. ? 1 case file where the applicant was identified as a fleeing felon, resulting in potential benefit overpayments of $763. ? 2 case files where the determination form was not signed by the caseworker, resulting in potential benefit overpayments of $958. Cause: Although the Department has established policies and procedures in place over the application process and the benefit calculation, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements, and resulted in questioned costs. Questioned Costs: $1,868 Identification of a repeat finding: N/A Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-010 Maintaining Proper Case Documentation to Support Eligibility Determinations Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.558 Program: Temporary Assistance for Needy Families Cluster Requirement: Eligibility Type of Finding: Non-Compliance and Material Weakness Federal award no. G1801HITANF 2018 and year: G1901HITANF 2019 Criteria: The State of Hawaii TANF State Plan (State Plan) provides the rules and regulations for the eligibility requirements of the TANF program subject to the requirements of 45 CFR 206.10. To apply for assistance, applicants must complete and file an application form, be interviewed by a caseworker, and have certain information verified. Further, to be eligible, the applicant must meet specific financial requirements. Condition: Eligibility determinations for 6 participants were not properly supported by the Department?s records or were not completed in accordance with the State Plan. Context: We selected a non-statistical sample of 60 participant files out of a population of approximately 7,000 cases for testing and noted exceptions in 6 case files as follows: ? 2 case files where the eligibility determination was completed outside of the required 45 day period. ? 1 case file where the benefit calculation was performed without using the current income information, resulting in potential benefit overpayments of $147. ? 1 case file where the applicant was identified as a fleeing felon, resulting in potential benefit overpayments of $763. ? 2 case files where the determination form was not signed by the caseworker, resulting in potential benefit overpayments of $958. Cause: Although the Department has established policies and procedures in place over the application process and the benefit calculation, there was a lack of diligence in complying with the policies and procedures. Effect: Failure to follow the established policies and procedures limits the Department?s ability to demonstrate compliance with the requirements, and resulted in questioned costs. Questioned Costs: $1,868 Identification of a repeat finding: N/A Recommendations: We recommend that the Department diligently comply with its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department continues to work with the Statewide Branch Administration (SBA) to enhance their existing case timeliness and efficiency monitoring on new application and on-going cases. We will advise the Section Administrators to continue printing monthly case reports to track each of the processing center?s processing time frames, alerts, and to include random reviews of cases to prevent avoidable errors. We will also recommend that the SBA have a ?resource folder? for the Eligibility staff to check individuals and case alerts to catch certain warnings on any existing disqualifications as fleeing felons. The Department also continues to work with the Staff Development Office (SDO) to ensure newly hired Eligibility staff are properly trained. The SDO will continue to emphasize the importance of Financial Application processing, Alerts, Notices, Income, Payment Determination, Proper Documentation, and Interviews in trainings. The Department will ensure that the Eligibility staff is using the most current updated Standard Desk Aid and ensure proper Participation Codes are used when processing through the HAWI system by providing a headline announcement of updates and reminders where everyone will be notified. Emphasis will be placed on diligence in complying with the policies and procedures to ensure compliance with the federal requirements. The Department is currently working on development of the Benefits Eligibility Solution (BES), the new eligibility system which will automate most of these processes and alerts. BES is projected to be operational within 2 years. Expected Completion Date: December 2022 Responding Official: Araceli Gamil, BESSD TANF Program Specialist
Income information for 7 participants were not properly supported by the Department?s records or were not completed in accordance with the Department?s policies and procedures. Context: We selected 60 case files for testing and noted 7 instances where the Department did not properly use the income information obtained through IEVS to re-evaluate the initial benefit calculations. KMH noted the following: ? 6 instances in which benefit payments totaling $2,240 were potentially overpaid to participants. ? 1 instance in which benefit payment of $505 was potentially underpaid to a participant. Cause: Program management indicated that there are policies and procedures in place regarding use of the IEVS but these policies and procedures were not consistently followed. Effect: Failure to properly use IEVS to evaluate benefit amounts resulted in potential over and under payments of benefits. Questioned costs: $2,240 Identification of a repeat finding: N/A Recommendations: The Department should be more diligent in consistently following its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-011 Income Eligibility and Verification System Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.558 Program: Temporary Assistance for Needy Families Cluster Requirement: Special Test ? Income Eligibility and Verification System Type of Finding: Non-Compliance and Material Weakness Federal award no. G1801HITANF 2018 and year: G1901HITANF 2019 Criteria: Title 45 CFR 205.55, requires the State agency to request through the Income Eligibility and Verification System (IEVS), wage information, unemployment compensation, Social Security Administration, unearned income, and any other income information. Condition: Income information for 7 participants were not properly supported by the Department?s records or were not completed in accordance with the Department?s policies and procedures. Context: We selected 60 case files for testing and noted 7 instances where the Department did not properly use the income information obtained through IEVS to re-evaluate the initial benefit calculations. KMH noted the following: ? 6 instances in which benefit payments totaling $2,240 were potentially overpaid to participants. ? 1 instance in which benefit payment of $505 was potentially underpaid to a participant. Cause: Program management indicated that there are policies and procedures in place regarding use of the IEVS but these policies and procedures were not consistently followed. Effect: Failure to properly use IEVS to evaluate benefit amounts resulted in potential over and under payments of benefits. Questioned costs: $2,240 Identification of a repeat finding: N/A Recommendations: The Department should be more diligent in consistently following its policies and procedures. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department will continue to work with the Statewide Branch Administrator to enforce and ensure that all Eligibility staff follow current procedures on IEVS. The Department will also work with the Staff Development Office to emphasize the importance of IEVS to all Eligibility staff and to provide clear instructions when changes in procedures occur. Expected Completion Date: December 31, 2020 Responding Official: Araceli Gamil, BESSD TANF Program Specialist
There were 6 participant files where appropriate action was not taken to comply with the requirements. Context: We selected a non-statistical sample of 10 participant files for testing, out of a population of 88 participant files, and noted 6 participant files which were initially determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. During our review, these 6 participant files did not contain any correspondence, notices, or documentation to indicate any follow up action, up to and including case closure and cessation of benefits, were performed. Consequently, there may be potential overpayments of benefits of $10,885. Cause: There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Effect: Failure to take appropriate action resulted in non-compliance with the requirements and questioned costs. Questioned Costs: $10,885 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-012. Recommendations: We recommend that the Department diligently perform the required procedures and to develop system controls to suspend benefits until non-cooperation is addressed. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-012 Maintaining Proper Case Documentation to Support Compliance with Child Support Non-Cooperation Requirement Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.558 Program: Temporary Assistance for Needy Families Cluster Requirement: Special Tests and Provisions - Child Support Non-Cooperation Type of Finding: Non-Compliance and Material Weakness Federal award no. G1501HITANF 2015 and year: G1701HITANF 2017 G1801HITANF 2018 G1901HITANF 2019 Criteria: 45 CFR section 264.30 states the Title IV-A agency must take appropriate action, as defined, if the Title IV-D agency determines that an individual is not cooperating with the child support enforcement requirements. Condition: There were 6 participant files where appropriate action was not taken to comply with the requirements. Context: We selected a non-statistical sample of 10 participant files for testing, out of a population of 88 participant files, and noted 6 participant files which were initially determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. During our review, these 6 participant files did not contain any correspondence, notices, or documentation to indicate any follow up action, up to and including case closure and cessation of benefits, were performed. Consequently, there may be potential overpayments of benefits of $10,885. Cause: There was a lack of diligence in following the Department?s established policies and procedures to ensure compliance with the requirements. Effect: Failure to take appropriate action resulted in non-compliance with the requirements and questioned costs. Questioned Costs: $10,885 Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-012. Recommendations: We recommend that the Department diligently perform the required procedures and to develop system controls to suspend benefits until non-cooperation is addressed. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department agrees with this finding and will implement corrective action. Corrective Action Taken or Planned: The Department continues to work closely with the Statewide Branch Administration to ensure that Eligibility staff inform clients of the child support cooperation requirements during the application and reapplication interview. Eligibility staff will be reminded that documentation is to be filed in the Electronic Case Folder and inputted into the HAWI system. Clients should also be sent appropriate notices. A report is sent monthly to the Branch of the noncompliance alerts received from CSEA and action should be taken to suspend benefits until non-cooperation is addressed. A HAWI system modification request has been submitted to the Department?s Office of Information Technology (OIT) to stop the system from purging CSEA non-cooperation alerts. The alert shall be manually cleared after appropriate action is taken by Eligibility staff. This will result in closer monitoring of the efficiency and timeliness of required actions. This will help reduce the amount of overpaid TANF benefits and prevent child support noncooperation by recipients. OIT has placed the modification request in its work prioritization queue. The Department is in the process of developing the Benefits Eligibility Solution (BES), a new eligibility system to replace HAWI. Program staff are working with an IT contractor to incorporate system solutions in BES to ensure Eligibility staff can take timely and appropriate action when CSEA notifies the Department of a client who fails to cooperate with child support activities. BES is expected to be operational in two years. Expected Completion Date: December 2022 Responding Official: Araceli Gamil, BESSD TANF Program Specialist
2018-012
The MOE reported on the originally submitted ACF-204 did not agree with the MOE reported on the ACF-196R. Context: We selected the annual ACF-204 report for the federal fiscal year 2018 for testing and noted the total MOE expenditures reported on the ACF-204 did not agree to the total MOE reported on the ACF-196R report. A revised ACF-204 report was submitted subsequent to the fiscal year under audit and is pending approval from the Federal Administration for Children and Families (ACF). Cause: The Department indicated that although there were established policies and procedures in place over the ACF 204 reporting, the procedures did not include a requirement to compare the MOE amount reported on the ACF-204 and the ACF 196R. Effect: Failure to properly report the correct data resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-013. Recommendations: We recommend the Department include procedures to compare the MOE amount report on the ACF-204 and the ACF-196R to ensure compliance with Federal regulations. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-013 Special Report Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.558 Program: Temporary Assistance for Needy Families Cluster Requirement: Reporting Type of Finding: Non-Compliance and Material Weakness Federal award no. and year: G1801HITANF 2018 Criteria: 45 CFR 265.9 requires each State to file an annual report containing information on the TANF program and the State's Maintenance of effort (MOE) program for that year. The special report ACF 204, Annual Report including the Annual Report on MOE Programs, is filed annually to meet this requirement. Further, the ACF 204 Instructions and the 2019 Compliance Supplement states that the MOE amounts claimed should equal the total MOE amounts claimed under all programs on the State's 4th quarter ACF 196R report. Condition: The MOE reported on the originally submitted ACF-204 did not agree with the MOE reported on the ACF-196R. Context: We selected the annual ACF-204 report for the federal fiscal year 2018 for testing and noted the total MOE expenditures reported on the ACF-204 did not agree to the total MOE reported on the ACF-196R report. A revised ACF-204 report was submitted subsequent to the fiscal year under audit and is pending approval from the Federal Administration for Children and Families (ACF). Cause: The Department indicated that although there were established policies and procedures in place over the ACF 204 reporting, the procedures did not include a requirement to compare the MOE amount reported on the ACF-204 and the ACF 196R. Effect: Failure to properly report the correct data resulted in non-compliance with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-013. Recommendations: We recommend the Department include procedures to compare the MOE amount report on the ACF-204 and the ACF-196R to ensure compliance with Federal regulations. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Views of responsible officials: The Department does not dispute this finding and have implemented corrective action. Corrective Action Taken or Planned: The Department will continue to utilize the worksheet templates that were developed to record and classify actual expenditures on the ACF-196R and ACF-204 reports. The worksheets include a ?cross-walk? to identify and map where State MOE and SSP-MOE expenditures on the ACF-196R are reported on the ACF-204 (i.e. Attachment B forms). This ?cross-walk? worksheet ensures the balances match on both reports, expenditures are reported in same/similar categories, and helps to identify any discrepancies between the reports. Policies and procedures will be updated to include the requirement to compare the MOE amount reported on the ACF-204 and the ACF-196R. BESSD continues to receive technical assistance from ACF Region 9 to finalize the FFY 2017 ACF-196R and ACF-204 reports. The Department will continue to forward the completed worksheet templates to ACF to review before the actual ACF-196R and ACF-204 reports are finalized and formally submitted. Expected Completion Date: Completed FFY 2018 ACF-204 July 2019. FFY 2017 ACF-196R and ACF-204 reports, are to be reviewed and finalized by 10/31/20. Pursuit of technical assistance from ACF will be on-going. Responding Officials: Catherine Scardino, BESSD Employment and Training Program Administrator, and Paul Higa, BESSD Financial Assistance Program Administrator
2018-013
4 quarterly data reports were incorrectly reported. Context: We selected all 4 quarterly data reports for testing. Each quarterly data report aggregates the information from approximately 7,000 case files. We selected a non-statistical sample of 60 case files for testing and noted the following: ? 2 quarterly reports where the key report line item ?Number of months countable toward the Federal time limit? were incorrectly reported for 2 case files. ? 1 quarterly report where the key report line item ?Relationship to Head-of-Household? was incorrectly reported for 1 case files. Cause: The Department indicated that the errors were due to the fact that information was not updated in its system in the period in which the report was generated. Effect: Failure to properly report the correct data resulted in non-compliance with the requirement. Further, 45 CFR 265.8 allows for a potential penalty to be imposed when the Department fails to comply with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-014. Recommendations: We recommend the Department update information into their system timely and accurately to ensure that the information reported is complete and accurate. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
Show full finding ▾Hide full finding ▴Finding No.: 2019-014 Quarterly Reporting Federal Agency: U.S. Department of Health and Human Services CFDA No.: 93.558 Program: Temporary Assistance for Needy Families Cluster Requirement: Reporting Type of Finding: Non-Compliance and Material Weakness Federal award no. G1801HITANF 2018 and year: G1901HITANF 2019 Criteria: 45 CFR 265.3 requires each State to collect on a monthly basis, and file on a quarterly basis, the data specified in the TANF Data Report. Condition: 4 quarterly data reports were incorrectly reported. Context: We selected all 4 quarterly data reports for testing. Each quarterly data report aggregates the information from approximately 7,000 case files. We selected a non-statistical sample of 60 case files for testing and noted the following: ? 2 quarterly reports where the key report line item ?Number of months countable toward the Federal time limit? were incorrectly reported for 2 case files. ? 1 quarterly report where the key report line item ?Relationship to Head-of-Household? was incorrectly reported for 1 case files. Cause: The Department indicated that the errors were due to the fact that information was not updated in its system in the period in which the report was generated. Effect: Failure to properly report the correct data resulted in non-compliance with the requirement. Further, 45 CFR 265.8 allows for a potential penalty to be imposed when the Department fails to comply with the requirement. Questioned Costs: None Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2018-014. Recommendations: We recommend the Department update information into their system timely and accurately to ensure that the information reported is complete and accurate. Views of Responsible Officials and Planned Corrective Action: See Correction Action Plan.
View of responsible official: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department will continue to communicate with the Statewide Branch Administration to remind Eligibility staff of application of policies and correct procedures when determining eligibility to ensure that the information reported is complete and accurate. The Department will also continue to work with the Staff Development Office to ensure financial training provides accurate information and instructions in determining a client?s TANF eligibility. Effective tools such as situational examples, timetables, and other visual modalities to demonstrate clear explanations and understanding of the policies of TANF program will be utilized in training. The Department will also continue to closely monitor active cases by requesting monthly TANF data reports from the Office of Information Technology to show TANF cases that are nearing their 60 months as well as detailed reports on system coding errors to ensure updated information will be input timely. Expected Completion Date: December 31, 2020 Responding Official: Araceli Gamil, BESSD TANF Program Specialist
2018-014
FAC accepted this audit on March 26, 2019 — management decision was due September 26, 2019.
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2017-002
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2017-003
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2017-004
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2017-006
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2017-005
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2017-015
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2017-009
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2017-010
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2017-011
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2017-012
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2017-013
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2017-008
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2016-002
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2016-014
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2016-004
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2016-005
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2016-003
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2016-006
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2016-007
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2016-010
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2016-012
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2016-011
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2016-015
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2016-018
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2016-019
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2016-020
FAC accepted this audit on March 27, 2017 — management decision was due September 27, 2017.
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2015-001
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2015-005
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2015-008
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2015-024
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2015-012
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2015-021
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2015-011
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2015-015
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2015-017
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2015-018
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2015-013
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2015-023
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2015-019
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2015-003
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2015-025
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