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