Corrective Action Plans

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Failure to submit REAC report Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the...
Failure to submit REAC report Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the residual receipts account. Proposed Completion Date: June 30, 2025
Failure to Return Residual Receipts to HUD Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus ca...
Failure to Return Residual Receipts to HUD Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the residual receipts account. Proposed Completion Date: June 30, 2025
Failure to deposit Surplus Cash in the Residual Receipts accounts Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus ca...
Failure to deposit Surplus Cash in the Residual Receipts accounts Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the residual receipts account. Proposed Completion Date: June 30, 2025
Deadline for Federal Single Audit Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the re...
Deadline for Federal Single Audit Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the residual receipts account. Proposed Completion Date: June 30, 2025
Finding 540428 (2024-002)
Significant Deficiency 2024
Reference Number: 2024-002 Name of Contact Person: Armine Trashian, Controller Corrective Action: The City will implement recommendations and maintain all compliance-related documentation to ensure all necessary documents are maintained in accordance with ongoing compliance requirements. Proposed...
Reference Number: 2024-002 Name of Contact Person: Armine Trashian, Controller Corrective Action: The City will implement recommendations and maintain all compliance-related documentation to ensure all necessary documents are maintained in accordance with ongoing compliance requirements. Proposed Completion Date: June 30, 2025
Finding 2024-002 – HOME Loans Affordable Period Monitoring Management’s Response or Department’s Response Management concurs with the finding. Views of Responsible Officials and Corrective Action The Department will provide training to staff on HOME monitoring requirements, updating policies a...
Finding 2024-002 – HOME Loans Affordable Period Monitoring Management’s Response or Department’s Response Management concurs with the finding. Views of Responsible Officials and Corrective Action The Department will provide training to staff on HOME monitoring requirements, updating policies and procedures, as necessary, to address all current regulatory requirements. The Department’s multifamily monitoring for all projects in the HOME period of affordability will be completed prior to June 30, 2025. As part of the monitoring process, the Department will document all records requiring annual or semi-annual oversight and review for compliance with HOME requirements. Should the monitoring result in any findings requiring corrective action, the Department will ensure all findings are addressed by September 30, 2025. Anticipated Completion Date May 2025 Contact Information of Responsible Official Name: Augustine Ramirez Title: Division Manager, DPWP Community Development Division Phone: 559-600-4266
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 cas...
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
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...
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
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 (“KOL...
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
View Audit 350226 Questioned Costs: $1
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 al...
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
View Audit 350226 Questioned Costs: $1
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 us...
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
View Audit 350226 Questioned Costs: $1
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” ...
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
View Audit 350226 Questioned Costs: $1
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 topic...
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
View Audit 350226 Questioned Costs: $1
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 contribute...
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
View Audit 350226 Questioned Costs: $1
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 recor...
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
View Audit 350226 Questioned Costs: $1
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 contribute...
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
View Audit 350226 Questioned Costs: $1
PLANNED CORRECTIVE ACTION - Enhance procedures to update Federally funded construction contracts to require the submission of weekly certified payrolls to the appropriate District personnel. ANTICIPATED COMPLETION DATE - Immediate RESPONSIBLE CONTACT PERSON - Brandon Esposito, Director of Finance
PLANNED CORRECTIVE ACTION - Enhance procedures to update Federally funded construction contracts to require the submission of weekly certified payrolls to the appropriate District personnel. ANTICIPATED COMPLETION DATE - Immediate RESPONSIBLE CONTACT PERSON - Brandon Esposito, Director of Finance
View Audit 350218 Questioned Costs: $1
A. Comments on Finding and Recommendations Comments: It is important to note that at no time did L. Hayes & Associates, Inc. (LHA), Managing Agent, use project funds for unrelated costs. This finding No. 2024-001 refers specifically to fraudulent check charges that were posted to the Hughes operatin...
A. Comments on Finding and Recommendations Comments: It is important to note that at no time did L. Hayes & Associates, Inc. (LHA), Managing Agent, use project funds for unrelated costs. This finding No. 2024-001 refers specifically to fraudulent check charges that were posted to the Hughes operating account in March 2024 by an unknown person. There was a total of three (3) checks written by the same person. This person is unknown to us and did not have access to our check stock nor our office. Therefore, it appears that the perpetrator used some type of machine to reproduce copies of our checks and the signature of Ms. Voundy-Thomas, Operations Manager. Recommendations: Based on the recommendation of our auditor, our office contacted the Maryland Banking Commission to report and pursue reimbursement of the fraudulent charges deducted from the Hughes Neighborhood Housing operating bank account and they referred us to contact the Office of the Comptroller of Currency. Our auditor also suggested that we discuss potential solutions with our HUD Account Executive. B. Actions Taken or Planned Actions Taken: Upon reconciliation of the Project’s March 2024 bank accounts and the discovery of the fraudulent charges, Ms. Voundy, Thomas immediately contacted Wells Fargo’s Fraud Claims Department to report our findings, request reimbursement of the charges, and to place an alert of the account. In addition, Ms. Voundy-Thomas and Mr. Merrick, Hughes, BOD President, visited a Wells Fargo branch to discuss this matter directly with an Account Representative. Unfortunately, the bank denied our request for reimbursement of the fraudulent charges stating that our claim was not processed within 30-days of the posted charges. Actions Planned: Per the guidance from the Maryland Banking Commission, our office has contacted the Office of the Comptroller of Currency to further pursue reimbursement of the fraudulent charges. Also, upon completion and submission of the above-mentioned audit, we plan to pursue any further actions recommended by our HUD Account Executive regarding this finding. Status of Corrective Action on Prior Findings No prior findings were noted.
View Audit 350209 Questioned Costs: $1
Finding Number: 2024 – 003 – Reporting Grantor: Department of Labor (DOL)-Office of Disability Employment Policy (ODEP) Program Name: Disability Employment Policy Development Award Name: Disability Employment Policy Development Award Number: 23475OD000001-01-00 (passthrough ID 24-SA-053-3203) Assist...
Finding Number: 2024 – 003 – Reporting Grantor: Department of Labor (DOL)-Office of Disability Employment Policy (ODEP) Program Name: Disability Employment Policy Development Award Name: Disability Employment Policy Development Award Number: 23475OD000001-01-00 (passthrough ID 24-SA-053-3203) Assistance Listing Titles: Disability Employment Policy Development Assistance Listing Numbers: 17.720 Award Year: Fiscal Year 2024 Passthrough Entity: The Council of State Governments Corrective Action Plan: Cornell acknowledges that performance reports for this award were not filed timely. To address this omission the university will reinforce the importance of timely reporting during routine training and update sessions in the coming year and remind departments that these requirements are stated in the award documents and the research administration system. Responsible individual: Mary-Margaret Klempa, Senior Director, Office of Sponsored Programs
Finding Reference: 2024-011 - Program Income, Ryan White (UMMC) Responsible Official: Mustafa Khawaja, Interim Director of Post-Award Corrective Action Planned: Based on feedback received from a Sponsor-led site visit in 2024, UMMC practices and policies are appropriately aligned with the intent of ...
Finding Reference: 2024-011 - Program Income, Ryan White (UMMC) Responsible Official: Mustafa Khawaja, Interim Director of Post-Award Corrective Action Planned: Based on feedback received from a Sponsor-led site visit in 2024, UMMC practices and policies are appropriately aligned with the intent of the program. UMMC will make efforts to ensure that all practices and policies are clearly documented and evaluated periodically. Estimated Completion Date: June 30, 2025
Finding Reference: 2024-007 - SFA Eligibility (ASU) Responsible Official: Juanita Edwards, Director of Financial Aid Corrective Action Planned: ASU disburses aid to students’ accounts once the student has completed registration. The student was enrolled and eligible for the Pell grant. The student h...
Finding Reference: 2024-007 - SFA Eligibility (ASU) Responsible Official: Juanita Edwards, Director of Financial Aid Corrective Action Planned: ASU disburses aid to students’ accounts once the student has completed registration. The student was enrolled and eligible for the Pell grant. The student had not completed registration, so Pell was not disbursed. Moving forward ASU will review all student accounts to ensure students have completed the registration process. If they have not completed registration timely, they will be notified. Once notified and registration is complete, Title IV funds will be disbursed to the students’ accounts. Checks and balances have been reviewed and implemented to ensure the process is completed timely. Estimated Completion Date: June 30, 2025
View Audit 350191 Questioned Costs: $1
Finding Reference: 2024-003 - SFA COD Reporting (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU reconciles Pell and federal direct student loans to COD monthly. The reconciliation is done timely, and ASU will continue to reconcile and pr...
Finding Reference: 2024-003 - SFA COD Reporting (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU reconciles Pell and federal direct student loans to COD monthly. The reconciliation is done timely, and ASU will continue to reconcile and provide evidence of review. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships; Ms. Lakesha Tubbs, Registrar; Adrienne Walls, Bursar Corrective Action Planned: In previous years, Jackson State University has extended the purge and registration dates to better serve a high number of students from underrepresented communities and low-income backgrounds, ensuring that they have the opportunity to complete the enrollment process. However, this practice has led to inaccurate reporting of enrollment dates. Moving forward, Jackson State University will work with new, continuing, and readmit students beginning in April 2025 through the start of the Fall 2025 semester on August 18, 2025, to ensure all enrollment materials are completed before the beginning of each term. As part of this effort, Jackson State University has redesigned its new student orientation process with the goal of ensuring students are completely registered before arriving on campus for the fall semester. Within this new model, a dedicated position has been created for First-Time Freshmen to establish proactive outreach and education regarding costs to students and families. The redesigned orientation process places a strong emphasis on First-Time Freshmen, guaranteeing they receive the necessary guidance and support to successfully transition into college life. Additionally, the university will enforce enrollment deadline dates to prevent inaccurate enrollment data and eliminate errors in disbursement records. In addition to enhancing the student enrollment process, JSU is also taking steps to strengthen financial accountability. Furthermore, Jackson State University’s Financial Aid Office, in coordination with its Business Office, will begin holding regularly scheduled reconciliation meetings at the end of each month. These meetings will ensure that the amounts disbursed on both sides align and that figures from both departments match what has been drawn down and either paid out or returned to the U.S. Department of Education Common Origination and Disbursement (COD). Both departments will also utilize an institutional reconciliation document to add another layer of control and prevent errors. These strategic improvements reflect Jackson State University’s ongoing commitment to compliance, operational efficiency, and student success. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (MVSU) Responsible Official: Angela Fant, Director of Financial Aid Corrective Action Planned: The internal control procedures will initiate a reconciliation of disbursement dates against COD data. Estimated Completion Date: September 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (UMMC) Responsible Official: Davita Weary, Director of Student Financial Aid Corrective Action Planned: Reconciliations will be reviewed with Kelly Dismuke, Director of Finance Operations, on a monthly basis. Estimated Completion Date: March 26, 2025 Finding Reference: 2024-003 - SFA COD Reporting (USM) Responsible Official: David Williamson, Director of Financial Aid Corrective Action Planned: USM reconciles Pell and DL monthly. Copies of reconciliations are saved in a shared drive and can be made available upon request. The reconciliations will be reviewed on a monthly basis by the Financial Aid Assistant Director (Alanna McDonald) and Director (David Williamson), and the Bursar (Barbara Madison) when necessary. Estimated Completion Date: March 17, 2025
Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: The Jackson State University Division of Financial Aid has implemented a co...
Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: The Jackson State University Division of Financial Aid has implemented a comprehensive training initiative to strengthen compliance, improve accuracy, and enhance staff proficiency in federal student aid verification. As of May 7, 2024, ongoing training has commenced for all financial aid staff on the 2024-2025 verification process and required documentation. Additionally, beginning April 4, 2025, the department will launch continuous training on verification procedures and Federal Student Aid compliance to ensure staff remains informed of regulatory updates and best practices. To further enhance accuracy and accountability, the department will collaborate with the Department of Information Technology (IT) to develop internal error reports that proactively identify discrepancies in student records. An internal checklist will also be implemented to ensure that each student selected for verification by the U.S. Department of Education has submitted all required documentation. This checklist must be reviewed and signed off by the Executive Director of Student Financial Aid Services and Scholarships before final processing. As part of the department’s transition to a more automated verification process, JSU will integrate Campus-Logic, powered by Ellucian, to streamline operations and reduce manual errors. Comprehensive training sessions will be conducted to ensure financial aid staff are proficient in using the platform. Additionally, an internal checklist within Campus-Logic will be established to facilitate structured review and compliance tracking. A final verification review will be conducted by the Executive Director of Student Financial Aid Services and Scholarships to uphold accuracy and federal compliance, ultimately mitigating errors and improving audit outcomes. Estimated Completion Date: December 19, 2025 Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (MVSU) Responsible Official: Angela Fant, Director of Financial Aid Corrective Action Planned: The verification process will ensure all student data is accurate and corrected by staff. Estimated Completion Date: September 30, 2025
Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (ASU) Responsible Official: Charlette Mock, Director of Accounting Corrective Action Planned: ASU uses a servicer to deliver ...
Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (ASU) Responsible Official: Charlette Mock, Director of Accounting Corrective Action Planned: ASU uses a servicer to deliver credit balance to students. The contract with the servicer should have been uploaded to the Dept of Ed database. Since the audit finding, the contract has been uploaded. ASU will upload the contract timely going forward. Estimated Completion Date: Effective Immediately Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (MVSU) Responsible Official: Mrs. Brittney Manuel-Carpenter, Account Receivable Supervisor Corrective Action Planned: MVSU acknowledged the findings of reference 2024-06 SFA-Special Test- Using a Servicer to Deliver Title IV Credit Balances. MVSU acknowledges that the servicer contract is uploaded to the Department of Education database and is available for viewing. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (USM) Responsible Official: David Williamson, Director of Financial Aid Corrective Action Planned: University will contact the Department of Education Cash Management to correct the URL link. While the link was broken on the Cash Management site it was active on the USM Business Services website: https://www.usm.edu/business-services/refunds.php and is continually maintained on their site. Estimated Completion Date: April 1, 2025
Finding Reference: 2024-004 - SFA Special Tests and Provisions - GLBA (MVSU) Responsible Official: Dameon A. Shaw, Vice President for Information Technology Corrective Actions Planned: 1. Develop a Comprehensive Information Security Program to ensure MVSU has a full information security program that...
Finding Reference: 2024-004 - SFA Special Tests and Provisions - GLBA (MVSU) Responsible Official: Dameon A. Shaw, Vice President for Information Technology Corrective Actions Planned: 1. Develop a Comprehensive Information Security Program to ensure MVSU has a full information security program that addresses all 7 required elements of the GLBA regulations: • Review GLBA Requirements: Conduct a thorough review of the Gramm-Leach-Bliley Act (GLBA) regulations to understand the 7 required elements. - Completed • Gap Analysis: A gap analysis has been performed to identify missing elements in the current information security program. - Completed • Program Development: Develop and implement policies and procedures to address the identified gaps. This includes administrative, technical, and physical safeguards. - In Progress • Training: Provide training to staff on the new policies and procedures to ensure compliance and proper implementation. - Planning • vCISO Support: Leverage the expertise of the newly hired virtual Chief Information Security Officer (vCISO) to guide the development and implementation of the information security program. - In Progress 2. Conduct a Comprehensive Risk Assessment to identify and address significant gaps in the risk assessment process: • Risk Assessment Framework: Establish a risk assessment framework that aligns with GLBA requirements. - In Progress • Identify Risks: Identify potential risks to the confidentiality, integrity, and availability of customer information. – In Progress • Evaluate Controls: Assess the effectiveness of existing controls and identify areas for improvement. – In Progress • Mitigation Plan: Develop a risk mitigation plan to address identified vulnerabilities and implement appropriate controls. - Planning • vCISO Support: Utilize the vCISO's expertise to ensure a thorough and effective risk assessment process. – In Progress 3. Monitoring and Continuous Improvement to ensure ongoing compliance and continuous improvement of the information security program: • Regular Audits: Conduct regular audits to ensure compliance with GLBA regulations and the effectiveness of the information security program. – Planning • Feedback Mechanism: Establish a feedback mechanism to gather input from staff and stakeholders on the effectiveness of the program. - Planning • Update Policies: Periodically review and update policies and procedures to address emerging threats and changes in regulations. – In Progress • vCISO Support: Engage the vCISO in monitoring and continuous improvement efforts to maintain high standards of information security. – In Progress 4. Reporting and Accountability to ensure accountability and transparency in the implementation of the corrective action plan: • Assign Responsibility: Assign responsibility for the implementation of the corrective action plan to a dedicated team or individual. - Planning • Progress Reports: Provide regular progress reports to senior management and stakeholders on the implementation of the corrective action plan. - Planning • Documentation: Maintain thorough documentation of all actions taken to address the identified issues. - Planning • vCISO Support: Include the vCISO in reporting and accountability processes to ensure expert oversight and guidance. – In Progress By following this corrective action plan and leveraging the expertise of the vCISO, MVSU can address the deficiencies in its information security program and risk assessment process, ensuring compliance with GLBA regulations and protecting customer information effectively. Estimated Completion Date: November 30, 2025
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