Corrective Action Plans

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Identification of a Repeat Finding
Identification of a Repeat Finding
This finding was reported as a federal award finding in the immediate previous audit as Finding 2022-002.
This finding was reported as a federal award finding in the immediate previous audit as Finding 2022-002.
Recommendation
Recommendation
We again recommend that HHHRC adhere to established policies and procedures requiring that appropriate documentation be received and maintained to evidence compliance with eligibility requirements during the in-take and re-assessment process for the RWB program.
We again recommend that HHHRC adhere to established policies and procedures requiring that appropriate documentation be received and maintained to evidence compliance with eligibility requirements during the in-take and re-assessment process for the RWB program.
HHHRC should also consider expanding on their policies for payer of last resort, with more specific criteria for documentation required to support compliance with this requirement.
HHHRC should also consider expanding on their policies for payer of last resort, with more specific criteria for documentation required to support compliance with this requirement.
Views of Responsible Officials and Planned Corrective Action
Views of Responsible Officials and Planned Corrective Action
HHHRC is continuing to implement its planned corrective action plan noted in the Current Status sections of the prior audit findings. To ensure further compliance, HHHRC hired a Case Management Assistant (CMA) in August 2023. The CMA’s responsibility includes reviewing client files to ensure require...
HHHRC is continuing to implement its planned corrective action plan noted in the Current Status sections of the prior audit findings. To ensure further compliance, HHHRC hired a Case Management Assistant (CMA) in August 2023. The CMA’s responsibility includes reviewing client files to ensure required documentation and certifications are present in the files and completed accurately. Additionally, the HIV leadership team has created a primary spreadsheet of all client’s receiving services and has assigned the monitoring of the spreadsheet to the CMA. This primary spreadsheet will assist the HIV team with tracking the receipt of documents, upcoming or expired certifications, and assist with document retrieval. The updated policies, improved training, along with the added support of the Quality Program Coordinator and Case Management Assistant should shore up gaps in the certification process.
March 21, 2024
March 21, 2024
US Department of Health and Human Services
US Department of Health and Human Services
HIV CARE Formula Grants
HIV CARE Formula Grants
Passed-through State of Hawaii Department of Health
Passed-through State of Hawaii Department of Health
1250 Punchbowl Street
1250 Punchbowl Street
Honolulu, HI 96813
Honolulu, HI 96813
Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2023 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745...
Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2023 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745 Fort Street, Suite 2100, Honolulu HI 96813
Significant Deficiency
Significant Deficiency
Finding 2023-001
Finding 2023-001
Eligibility
Eligibility
U.S. Department of Health and Human Services
U.S. Department of Health and Human Services
CFDA No. 93.917
CFDA No. 93.917
During the in-take and re-assessment process for the Ryan White HIV/AIDS Part B (RWB) program, case managers are responsible for (1) ensuring that all required forms and documents are received from clients, (2) reviewing those forms and documents for completeness and accuracy to verify that RWB prog...
During the in-take and re-assessment process for the Ryan White HIV/AIDS Part B (RWB) program, case managers are responsible for (1) ensuring that all required forms and documents are received from clients, (2) reviewing those forms and documents for completeness and accuracy to verify that RWB program eligibility requirements are met; and (3) inputting the client’s information into e2 Hawaii, HHHRC’s system to monitor and track all RWB program clients. Effective April 1, 2022, HHHRC updated their policies and procedures, requiring a manager or knowledgeable employee other than the case manager to sign off on the certification forms to document their review of eligibility determinations for completeness and accuracy.
We selected a sample of 60 clients receiving assistance under the RWB program as part of our eligibility testing. Within the 60 files, we examined 4 annual or semi-annual certification forms dated prior to April 1, 2022, and 56 annual or semi-annual certification forms dated April 1, 2022 or later.
We selected a sample of 60 clients receiving assistance under the RWB program as part of our eligibility testing. Within the 60 files, we examined 4 annual or semi-annual certification forms dated prior to April 1, 2022, and 56 annual or semi-annual certification forms dated April 1, 2022 or later.
Of the 4 certification forms dated prior to April 1, 2022, we noted 3 certification forms did not contain evidence of a review performed by a manager or a knowledgeable employee other than the case manager.
Of the 4 certification forms dated prior to April 1, 2022, we noted 3 certification forms did not contain evidence of a review performed by a manager or a knowledgeable employee other than the case manager.
Of the 56 certification forms dated April 1, 2022 or later, we noted 3 certification forms were not signed off by a manager or knowledgeable employee other than the case manager.
Of the 56 certification forms dated April 1, 2022 or later, we noted 3 certification forms were not signed off by a manager or knowledgeable employee other than the case manager.
Of the 32 certification forms dated April 1, 2022 or later, we noted 6 certification forms were not signed off by a manager or knowledgeable employee other than the case manager.
Of the 32 certification forms dated April 1, 2022 or later, we noted 6 certification forms were not signed off by a manager or knowledgeable employee other than the case manager.
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