Corrective Action Plans

Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2025 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, 2025 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

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

FEDERAL AWARD FINDINGS AND QUESTIONED COSTS

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Significant Deficiency

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Finding No. 2025-001

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Activities Allowed or Unallowed / Allowable Costs / Cost Principles

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

U.S. Department of Health and Human Services

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Federal Assistance Listing Number 93.917

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Condition

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted one instance where HHHRC ...

During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted one instance where HHHRC determined that the client met the eligibility requirements and incurred certain costs which were charged to the RWB program. However, we found that the client exceeded the income threshold to be considered low-income, as defined by the state. Accordingly, this client was not eligible to participate in the RWB program and any costs charged to the RWB program were unallowable.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Criteria

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification ...

Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements. To be eligible, clients must have a medical diagnosis of HIV/AIDS and be (a) a low-income individual, (b) a resident of the state, and (c) uninsured or underinsured, as defined by the state. Eligibility determination is required before participation in the RWB program during the in-take process. Re-assessments are performed at least once every 12 months thereafter.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client...

Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client attesting to no income or very low income.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Additionally, costs associated with clients determined to be ineligible to receive assistance under the RWB program are unallowable.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Cause

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

HHHRC did not adhere to established policies and procedures requiring that the client meet all eligibility requirements during the in-take and re-assessment process before costs are charged to the RWB program.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Effect

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI