Corrective Action Plans

Finding 398364 (2023-002)

Significant Deficiency 2023

Brazos Valley Council on Alcohol and Substance Abuse

TX

Questioned Costs Allowable Costs / Cost Principles Reporting

BVCASA agrees and has already taken corrective action by reconfiguring the system to break out reportable and nonreportable expenditures to ensure the appropriate amount of indirect costs is reported as well as performing a more detailed review of the indirect cost allocation each month.

View Audit 307039 Questioned Costs: $1

Finding 398261 (2023-001)

Material Weakness 2023

Bremerton School District No. 100-C

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of District contact person: Cathie Seevers 134 Marion Ave N Bremerton, WA 9...

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of District contact person: Cathie Seevers 134 Marion Ave N Bremerton, WA 98312 360-473-1034 Corrective action the auditee plans to take in response to the finding: This audit finding is for ECF Funds that were awarded through the FCC. While we thought we complied when purchasing chrome books for hybrid learning, there were some other requirements that we were not able to document. Because our asset management system does not retain a list of previous ‘owners’ of each chrome book (the system replaces that student with the new student’s name and does not keep the history) we were unable to tell you exactly what student had several of our chrome books at that snapshot in time. We are now aware of the importance of this feature and will record these differently to maintain a history of users. BSD does not intend to use any more ECF funds. Anticipated date to complete the corrective action: May 1, 2024

View Audit 306962 Questioned Costs: $1

Finding 398242 (2023-001)

Material Weakness 2023

White Pass School District No. 303

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Angela Bowen 516 Silverbrook Rd, Randall, WA 98377 360-497-3791 Corrective action t...

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Angela Bowen 516 Silverbrook Rd, Randall, WA 98377 360-497-3791 Corrective action the auditee plans to take in response to the finding: The White Pass School District will immediately implement the following controls to assure that the District has adequate internal controls in place for any future expenditures for Capital Projects where federal funds will be used. 1-The District will review the Federal Procurement and contractor requirements prior to submitting applications to use federal funds for Capital Projects. 2- The District will have a meeting with the appropriate staff involved with the project to insure that compliance with the Federal Program Procurement including compliance with the federal wage rate requirements are met. 3- As part of the verification process to ensure adequate internal controls the District will identify who the person will be who will secure and monitor weekly certified payroll from the contractors to stay in compliance with the federal wage rate requirements at the beginning of each project. Anticipated date to complete the corrective action: Effective immediately 5/13/2024

View Audit 306916

Finding 398229 (2023-004)

Significant Deficiency 2023

Las Virgenes Unified School District

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.439

Federal ESSER Funding was released in waves following the COVID-19 pandemic. The compliance for reporting and audits of these pandemic-related funds was new for staff across the state of California. Given this, staff did not send a capital outlay pre-approval request for technology equipment. Furthe...

Federal ESSER Funding was released in waves following the COVID-19 pandemic. The compliance for reporting and audits of these pandemic-related funds was new for staff across the state of California. Given this, staff did not send a capital outlay pre-approval request for technology equipment. Furthermore, more close oversight was needed regarding a multi-year subscription for a technology firewall that exceeded the grant timelines. Moving forward, the CBO and Assistant Directors of Finance and Accounting will work to ensure there are more layers of approval for Capital Outlay expenditures, especially as they relate to restricted categorical resources.

View Audit 306901 Questioned Costs: $1

Finding 398167 (2023-001)

Significant Deficiency 2023

Coxhealth

MO

Questioned Costs Allowable Costs / Cost Principles Reporting

Calculation errors identified during the 2023 Single Audit resulted in a variance between lost revenues and federal program funding received. To correct this variance, lost revenue calculations were updated to adjust patient care revenue to better align with program funding requirements for applica...

Calculation errors identified during the 2023 Single Audit resulted in a variance between lost revenues and federal program funding received. To correct this variance, lost revenue calculations were updated to adjust patient care revenue to better align with program funding requirements for applicable periods. To account for the questioned costs identified, additional expenses of approximately $460,000 were identified and meet program requirements for allowable expenses related to prevention, mitigation, and response to COVID-19.

View Audit 306883 Questioned Costs: $1

Finding 398164 (2023-001)

Significant Deficiency 2023

Center for Applied Linguistics

DC

Allowable Costs / Cost Principles Period of Performance Subrecipient Monitoring § 200.210 § 200.331

As of January 2, 2024 CAL, hired a staff account (Melanie Richards) to ensure all expenses are recorded in compliance with performance periods. The Associate Director of Finance will review all postings monthly and consult with the Vice President of Finance on any corrections or recommendations.

View Audit 306874

Finding 398066 (2023-001)

Significant Deficiency 2023

Dighton-Rehoboth Regional School District

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

May 14, 2024 CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Elementary and Secondary Education The Dighton-Rehoboth Regional School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public a...

May 14, 2024 CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Elementary and Secondary Education The Dighton-Rehoboth Regional School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 Audit period: July 1, 2022 through June 30, 2023 The following findings from the June 30, 2023, schedule of findings and question costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. 2023-001: Document Policies and Procedures Over Federal Awards (Significant Deficiency) Criteria or Specific Requirement - OMB’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards established significant new requirements related to Federal awards. The new requirements stipulate that federal award recipients must document their policies and procedures over certain aspects of financial and program management. Specifically, written policies are required for the following: Cash management Determination of allowable costs Employee travel Procurement Subrecipient monitoring and management Condition and Context – The District has not formalized written policies and procedures related to Federal awards as required under Uniform Guidance. Effect - The District is not in compliance with grant requirements. Cause - Weaknesses in the formal documentation of internal controls. Questioned Costs - N/A Recommendation - We recommend the District ensure that written policies and procedures are compiled and adopted. Views of Responsible Official and Planned Corrective Action Management agrees with this finding and is actively in the process of resolving this issue. This issue will be resolved by the end of FY24. The District has been working with Clifton Larson Allen LLP to draft policies and procedures for the District. If the Oversight Agency has questions regarding this plan, please call Bill Runey at 508-252-5000. Sincerely yours, Bill Runey Superintendent

View Audit 306794

Finding 398065 (2023-002)

Significant Deficiency 2023

Lee County, Florida

FL

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.302 § 200.303 § 200.403

2023-002 Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the County establish internal control procedures to ensure that all amounts charged to grant programs for employee payroll costs be reconciled to the specific employee payroll records and...

2023-002 Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the County establish internal control procedures to ensure that all amounts charged to grant programs for employee payroll costs be reconciled to the specific employee payroll records and that supporting documentation be maintained throughout the grant award period and beyond. Views of responsible officials: Management concurs with the finding. There were minimal variances in the number of employees tested and the County believes the wage report discrepancies are isolated due to the complexity of the EMS salary structure. The County claimed $26,038,852 of the $37,618,256 total eligible expenses available. Action planned/taken in response to finding: Effective fiscal year 2024, Management will implement the following corrective action: The County will create a process to ensure the payroll wage reports generated by Human Resources agrees to support documentation. Name of the contact person responsible for corrective action plan: Pete Winton Planned completion date for corrective action plan: The above action plan will be implemented in fiscal year 2024.

View Audit 306784 Questioned Costs: $1

Finding 398044 (2023-001)

Material Weakness 2023

Royal School District No. 160

WA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of District contact person: Greg Pike 901 Ahlers Ave, Royal City, WA 9935...

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of District contact person: Greg Pike 901 Ahlers Ave, Royal City, WA 99357 509-346-2222 Corrective action the auditee plans to take in response to the finding: The District is committed to implementing procedures that will ensure compliance with allowable activities as recommended by the State Auditor’s Office. The District was awarded ECF program funds on a one-time basis and has no plans to pursue such funding in the future. Nevertheless, the District will work with staff to align and implement specific procedures around the utilization of ECF program funds. Anticipated date to complete the corrective action: August 31, 2024

View Audit 306761 Questioned Costs: $1

Finding 398038 (2023-001)

Material Weakness 2023

Riverside School District No. 416

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Riverside School District No. 416 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of ...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Riverside School District No. 416 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Lisa Bjorklund, Business Manager Riverside School District No. 416 34515 N Newport Hwy Chattaroy, WA 99003-9734 Corrective action the auditee plans to take in response to the finding: In the future the district will comply with the federal prevailing wage requirements as part of our internal control process. Riverside will provide a weekly statement for all federal prevailing wage contracts; contracts will have all applicable Davis Bacon language in the contract prior to the start of any work. Riverside will comply with all applicable under Title 2 CFR Part 200, Title 29 CFR Section 3.3, and Title 29 CFR Section 5.5. Anticipated date to complete the corrective action: The corrective action will be in place as of May 20, 2024.

View Audit 306759

Finding 398037 (2023-001)

Material Weakness 2023

Rochester School District No. 401

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Rochester School District No. 401 September 1, 2022 through August 31, 2023 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Re...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Rochester School District No. 401 September 1, 2022 through August 31, 2023 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, and restricted purpose requirements. Name, address, and telephone of District contact person: Jill Pratt, Business Manager 10140 Hwy 12 SW Rochester, WA 98579 360-273-5536 Corrective action the auditee plans to take in response to the finding: We do not concur with the finding because 1,898 students were identified as having “unmet need” and 1,000 Chromebooks were purchased with grant funds. However, in the future we will document our processes differently. The District did conduct a survey of families and identified 1,898 students were in need of a school issued device. This grant purchased 1,000 Chromebooks. Every student in Rochester received a district issued Chromebook. In our inventory process, we did not tie the newly purchased Chromebooks to students identified as having a need; however, all those in need received a district device. Even though we locally determined every student had a need in order to succeed at remote learning, moving forward, we will ensure the federally purchased devices are checked out specifically to those determined to have an “unmet need” based on the federal definition. Anticipated date to complete the corrective action: We will work with the FCC to resolve this issue according to their timeline.

View Audit 306754 Questioned Costs: $1

Finding 398025 (2023-001)

Material Weakness 2023

Southside School District No. 42

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Paul Wieneke, Southside School District 161 SE Collier Rd Shelton, WA 98584 (360) 426-8437 Corrective ac...

Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Paul Wieneke, Southside School District 161 SE Collier Rd Shelton, WA 98584 (360) 426-8437 Corrective action the auditee plans to take in response to the finding: When engaging in any future state or federally funded capital project, the district will implement further internal controls to ensure compliance with all prevailing wage requirements. The district will keep a record of communication with the contractor, noting the date and time that weekly prevailing wages are monitored and are confirmed as accurate. The district will provide additional training to ensure staff overseeing compliance with federal programs are aware of all applicable requirements. Anticipated date to complete the corrective action: May 6, 2024

View Audit 306722

Finding 398022 (2023-002)

Significant Deficiency 2023

Pine Bluff School District

AR

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Response: The District concurs with this finding. District Management understands the importance of following approved policies and ensuring any incentive pay meets the approved guidelines within such policies.

View Audit 306717 Questioned Costs: $1

Finding 398022 (2023-002)

Significant Deficiency 2023

Pine Bluff School District

AR

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The District will follow the recommendation of Arkansas Legislative Audit and contact the Arkansas Division of Elementary and Secondary Education for guidance regarding this matter and implement proper controls over program expenditures.

View Audit 306717 Questioned Costs: $1

Finding 398022 (2023-002)

Significant Deficiency 2023

Pine Bluff School District

AR

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Corrective Action Taken: Corrective action has been implemented to ensure the District maintains proper controls over program expenditures. The Director of Federal Programs reviews and approves all

View Audit 306717 Questioned Costs: $1

Finding 397987 (2023-010)

Significant Deficiency 2023

Boys and Girls Club of Dane County, Inc.

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Recommendation: Timecards should reflect all time, or 100% effort of each employee’s total hours actually spent on work within the scope of his or her employment regardless of how many or how few hours an employee works. Effort certification must reflect actual work performed and cannot be budget dr...

Recommendation: Timecards should reflect all time, or 100% effort of each employee’s total hours actually spent on work within the scope of his or her employment regardless of how many or how few hours an employee works. Effort certification must reflect actual work performed and cannot be budget driven or assigned. A written time and effort policy and procedures should be designed and implemented to meet grantor requirements and recordkeeping requirements of the organization. Ac􀆟on Taken: A cost allocation plan has now been established and will be reviewed by our Board. Timecards for all staff, including salaried staff, are now being filled out with actual hours spent per grant versus budgeted hours and for each grant coded, there are high level comments to explain what work was accomplished for the grant. There is also now a Financial Specialist on staff that reviews timecards for accuracy in this regard. The contact person responsible for this corrective action plan is Wendi Speed, CFO, as well as the HR team that will implement the policy. The anticipated completion date is June 30, 2025.

View Audit 306700

Finding 397986 (2023-009)

Material Weakness 2023

Boys and Girls Club of Dane County, Inc.

WI

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Recommendation: Additional procedures should be designed, implemented, and documented for allowable costs to ensure documentation of review and approval of allowable costs to be charged to the federal award. The accounting system configurations should be modified to require segregation of duties for...

Recommendation: Additional procedures should be designed, implemented, and documented for allowable costs to ensure documentation of review and approval of allowable costs to be charged to the federal award. The accounting system configurations should be modified to require segregation of duties for all transactions. For journal entries, a documented review and approval should be performed by a finance committee member on a monthly basis. Ac􀆟on Taken: BGCDC has received instructions on how to configure the Accounts Payable module to incorporate the proper approval process. We are in the process of making that update. In addition, for any journal entries made the by CFO, a monthly list will go to the Finance Committee for review. The CFO tries to not make journal entries, but with limited Finance staff and a large workload, this is often inevitable. The logical approvals would come from Finance Committee. The contact person responsible for corrective action is Wendi Speed, CFO. The anticipated completion date is June 30, 2025.

View Audit 306700

Finding 397982 (2023-005)

Material Weakness 2023

Boys and Girls Club of Dane County, Inc.

WI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.403

Recommendation: Transactions should be recorded in accordance with GAAP with a review and approval for financial reporting as well as for compliance with allowability requirements. Training on cost principles per the Uniform Guidance should be provided to the finance department and program managers....

Recommendation: Transactions should be recorded in accordance with GAAP with a review and approval for financial reporting as well as for compliance with allowability requirements. Training on cost principles per the Uniform Guidance should be provided to the finance department and program managers. Ac􀆟on Taken: This transaction happened early on when the WIG grant was first awarded. Soon after, it was apparent this had been done incorrectly. The current Finance staff has attended a two-day Uniform Guidance training course and continues to read and review 2 CFR 200 regularly. If a transaction is in question, we reach out to auditors/consulting team. The corrective action planned is continual training on Uniform Guidance and the addition of a Compliance Director to our team. The contact person responsible for the corrective action is Wendi Speed, CFO. The anticipated completion date is June 30, 2025.

View Audit 306700 Questioned Costs: $1

Finding 397971 (2023-001)

Significant Deficiency 2023

Memphis Area Legal Services, Inc.

TN

Allowable Costs / Cost Principles

MALS has sent an initial email to LSC for approval of revised Allocation Methodology which covers the Administrative Salaries using a 2 step method for allocating Administrative Salaries. First, using Direct Hours charged to each grant as a percentage of Total Administrative Salaries. Then, for thos...

MALS has sent an initial email to LSC for approval of revised Allocation Methodology which covers the Administrative Salaries using a 2 step method for allocating Administrative Salaries. First, using Direct Hours charged to each grant as a percentage of Total Administrative Salaries. Then, for those grants that don't cover Administrative Salaries, those will be split between LSC and TN Filing Fees based on # of Closed Cases. Time by Direct Hours charged will be done on a monthly basis. Then, for those grants that don't cover Administrative Salaries, a quarterly true-up based on # of Closed Cases will be done. In addition, in 2Q2024 MALS is redefining the role and responsibilities of the CFO position. The position will be redefined as a full-time Director of Finance and Grant Compliance with clearly articulated financial oversight and Internal Control Compliance and Reporting responsibilities and overall responsibility for grant tracking and compliance.

View Audit 306682

Finding 397870 (2023-002)

Significant Deficiency 2023

Msad #27

ME

Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303

Significant Difficiencies, 2023-002 Allowable Costs ond Activities: There is an audit recommendation that the District implement internal control processes and procedures to ensure that each purchase has a purchase order and an approved invoice at the time of payment, clearly indicating pre-approval...

Significant Difficiencies, 2023-002 Allowable Costs ond Activities: There is an audit recommendation that the District implement internal control processes and procedures to ensure that each purchase has a purchase order and an approved invoice at the time of payment, clearly indicating pre-approval for the purchase and coding to ensure it is charged to the correct accounts. Corrective Action: The District already has a requisition/purchase order system in place and will expand it to ensure purchases are pre-approved and that invoices are approved and that the purchase is coded to the appropriate fund. Anticipated Completion Date: This con-ective action has already been implemented during the 2023-2024 fiscal year, once identified by our auditors while they were performing our 2022-2023 audit.

View Audit 306609

Finding 397575 (2023-079)

Material Weakness 2023

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 ...

Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees that it did not meet the Nursing Home Recertification Survey requirements, due to the backlog created by the public health emergency and a 20 percent staff vacancy rate. The Department does not agree that it was due to lack of internal controls. It was through applied internal controls that we identified the need to hire a contractor to assist with the recertification backlog to meet compliance requirements. As of March 2024, the Department met the 15.9-month recertification timeline. The 12.9-month statewide average is based on the overall average of months for all nursing home surveys, which included some of those surveys that were in a significant backlog due to the pandemic. Statistically, even when the state is meeting the 15.9-month timeframe for each home and lowering the number of months between surveys, it is expected that the bell curve average will take time to shift toward 12.9 months. The Department believes this will be achieved by January 2026. The conditions noted in this finding were previously reported in finding 2020-054. Completion Date: Estimated January 2026 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 306534

Finding 397574 (2023-078)

Material Weakness 2023

State of Washington C/o Office of Financial Management

WA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid intermediate care facilities. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 C...

Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid intermediate care facilities. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID 93.778 93.778 COVID Amount $0 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees that it did not meet the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) Survey requirements, due to the backlog created by the public health emergency and a 20 percent staff vacancy rate. The Department does not agree that it was due to lack of internal controls. It was through applied internal controls that we identified concerns and were able to allocate resources to meet the most serious concerns. As of March 2024, the Department: • Met the 15.9-month recertification timeline. • Created a statement of deficiency and plan of correction tracking tool in Smartsheet for each team in Residential Care Services to track deadlines. This system generates automatic email alerts to key staff on approaching deadlines and when recertification deadlines have arrived. The 12.9-month statewide average is based on the overall average of months for all ICF-IID surveys, which included some of those surveys that were in a significant backlog due to the pandemic. Statistically, even when the state is meeting the 15.9-month timeframe for each home and lowering the number of months between surveys, it is expected that the bell curve average will take time to shift toward 12.9 months. The Department believes this will be achieved by January 2026. The conditions noted in this finding were previously reported in findings 2020-053, 2019-061, 2018-052, 2017-042, 2016-037, 2015-045, 2014-046. Completion Date: Estimated January 2026 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 306534

Finding 397573 (2023-077)

Material Weakness 2023

State of Washington C/o Office of Financial Management

WA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid Program. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $5...

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid Program. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $576,072 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees that the Medicaid Provider Disclosure Statement (MPDS) forms for the identified exceptions were not obtained within the five-year revalidation timeline due to the increased workload during the public health emergency. The Department does not agree all the exceptions should result in questioned costs. The Department is disputing the questioned costs related to one nursing home, totaling $231,810. Although the MPDS was not submitted within the five-year revalidation timeline, the Department determined there were no changes to ownership or managing employees since the previous MPDS form was received. As of March 2023, automated provider screenings are completed monthly for all providers as required. As of March 2024, the Department’s nursing home revalidation process was modified to provide guidance to staff when a nursing home does not provide the required MPDS during the 5-year revalidation period. The process includes procedures prior to termination of the contract to ensure resident safety and choice, as well as when to stop payment. By December 2024, the Department will consult with the U.S. Department of Health and Human Services (HHS) regarding the disagreement with the $231,810 of questioned costs. The Department will work with HHS regarding the remaining $344,262 of questioned costs and take additional action as appropriate. The conditions noted in this finding were previously reported in finding 2022-059. Completion Date: Estimated December 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 306534 Questioned Costs: $1

Finding 397571 (2023-075)

None 2023

State of Washington C/o Office of Financial Management

WA

Questioned Costs Allowable Costs / Cost Principles

Finding: The Health Care Authority improperly charged $3,491 to the Medicaid program. Questioned Costs: Assistance Listing # 93.778 93.778 COVID-19 Amount $3,491 Status: Corrective action not taken Corrective Action: The Authority partially concurs with the finding. The condition identi...

Finding: The Health Care Authority improperly charged $3,491 to the Medicaid program. Questioned Costs: Assistance Listing # 93.778 93.778 COVID-19 Amount $3,491 Status: Corrective action not taken Corrective Action: The Authority partially concurs with the finding. The condition identified by the auditors was the result of federal requirements in place during the COVID-19 public health emergency. The condition will be addressed by existing procedures during the unwinding process. No corrective action is necessary. In accordance with 42 U.S.C. § 1396b(u), questioned costs will not be repaid as they do not exceed the allowable error rate of three percent of total expenditures verified by the Center for Medicare and Medicaid Services Payment Error Rate Measurement process. Completion Date: Not applicable Agency Contact: William Sogge, CPA, CIA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov

View Audit 306534 Questioned Costs: $1

Finding 397517 (2023-062)

Material Weakness 2023

State of Washington C/o Office of Financial Management

WA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.403 § 200.410 § 200.53

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with financial reporting requirements for the Child Care and Development Fund Cluster. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Status: Correc...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with financial reporting requirements for the Child Care and Development Fund Cluster. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Status: Corrective action in progress Corrective Action: The Child Care and Development Fund (CCDF) program was previously managed by the Department of Social and Health Services and the Department of Early Learning. Since the program transitioned in 2019, the Department has been making efforts to strengthen internal controls over payments to child care providers and other CCDF grant requirements. The Department implemented grant-level management of all federal funds, including the CCDF grant. The Department allocated the CCDF grant to eligible clients and allowable activities in compliance with 45 CFR 98.67. As part of the audit resolution process, the Department of Health and Human Services (HHS), Administration for Children & Families (ACF), which oversees the CCDF program at the federal level, reviews all State Auditor’s Office (SAO) findings and issues management decision letters. The Department received a management decision letter dated October 3, 2023, from HHS for finding 2021-033 (2020-038) which states: “The ACF noted that the auditor raised concern about the Department’s accounting procedures and efforts made to trace expenditures at the transaction-level. As the basis for the finding, the auditor used CFRs (200.53, 200.303, 200.403, 200.410) that do not apply to CCDF. Federal regulations allow Lead Agencies to expend and account for CCDF funds in accordance with their own procedures.” In addition, ACF did not sustain the disallowance of questioned costs and stated: “Although the Department’s internal controls were lacking, the ACF has not identified any funds that were expended on ineligible activities.” The ACF recommended: “…that the Department work with the auditors to determine an appropriate methodology that can be tested to ensure child care payments comply with Federal regulations.” The Department met with ACF and SAO on November 8, 2023, to discuss the ACF decision at which time ACF upheld the above statements that the activities allowed finding was not substantiated. The Department is committed to collaborating with SAO to determine an appropriate methodology that identifies a sampling unit that can be used to accurately test compliance. The SAO maintained that the program is not auditable without child-level data. The Department does not currently have the staff and resources to develop and maintain the business process redesign, as well as the information technology initiatives necessary to meet the level of assurance recommended by SAO. In response to the auditor’s recommendations, the Department submitted a budget request for the 2024 supplemental budget. Funding was provided to develop and maintain the business process that would allow adjustments to include child-level data beginning July 2024. The conditions noted in this finding were previously reported in findings 2022-044 and 2021-038. Completion Date: Estimated December 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

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