Corrective Action Plans

Finding 19718 (2022-062)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.1 § 200.410

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to report recoveries of fraudulent overpayments on the CMS-64 report. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 Amount $977,612 Stat...

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to report recoveries of fraudulent overpayments on the CMS-64 report. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 Amount $977,612 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority has established a process to ensure information concerning the status of Medicaid Fraud Control Unit (MFCU) cases is communicated timely to the Authority from the Attorney General?s Office. The Authority has documented the process to ensure recoveries of fraudulent overpayments are reported on the CMS-64 report appropriately and any federal share is returned timely to the Centers for Medicaid & Medicare Services (CMS). The Authority agrees that $1,032 needs to be repaid to CMS and will initiate return of those funds. The Authority does not concur that the remaining $976,580 needs to be returned to CMS. The state pursued assets through its available means and the court. The provider in question has been out of business since 2017 and a final court ruling was made in June 2022. In April 2023, the Attorney General?s Office certified the defaulted corporation had no identifiable assets. In accordance with 42 CFR 433.318(d), the provider is out of business and the Authority is not required to return the overpayment to CMS. The Authority will provide the court documentation and Attorney General?s certification to CMS Audit Resolution. The conditions noted in this finding were previously reported in findings 2021-052 and 2020-050. Completion Date: Estimated September 2023 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

View Audit 23129 Questioned Costs: $1

Finding 19717 (2022-061)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it performed procedures to safeguard against unnecessary utilization of care and services for the Medicaid program. Questioned Costs: Assistance Listing # 93.775 93.7...

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it performed procedures to safeguard against unnecessary utilization of care and services for the Medicaid program. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority has received guidance from the Centers for Medicare & Medicaid Services (CMS) and will adjust the state plan based on CMS requirements. Per CMS guidance, this adjustment will not include separately listing the methods and procedures it uses to safeguard against unnecessary utilization of care and services. The Authority does not concur with the auditor?s conclusion regarding its statewide surveillance and utilization control program not meeting federal program integrity requirements. The Authority?s program meets CMS standards and requirements and provides reasonable oversight. The Authority will update its policies and procedures related to the program. The Authority concurs that the two providers of the Program of All-inclusive Care for the Elderly (PACE) were not monitored for their compliance with the False Claims Act (FCA) during the fiscal year. The Department of Social and Health Services (DSHS) manages the contracts for the PACE program, but payments to these providers are routed through the Authority?s ProviderOne system. The process for PACE provider monitoring has been clarified with DSHS who is responsible for providing FCA oversight for these contracts. The conditions noted in this finding were previously reported in findings 2021-050, 2020-047, 2020-048, 2019-052, 2019-053 and 2018-047. Completion Date: Estimated December 2023 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

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Finding 19716 (2022-060)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it periodically audited cost report data for rate setting, hospital billings, and other financial and statistical records for inpatient hospital services. Questioned Cost...

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it periodically audited cost report data for rate setting, hospital billings, and other financial and statistical records for inpatient hospital services. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority does not agree it did not comply with federal requirements related to audits of inpatient hospitals. The Authority performs the following procedures: Cost report data for rate setting: ? Audits Medicaid cost report schedules and supporting documentation used for the Certified Public Expenditure Program. ? Audits critical access hospital data and uses final audited Medicare cost reports for settlement. ? Reviews and audits hospital cost reports using the ratio of costs-to-charges payment method. Hospital billings: ? Annual audits of hospital billings. Other financial and statistical records: ? Audits disproportionate share hospital reimbursements. The Authority concurs that documentation of the different hospital audits performed could be more clearly defined and will formalize procedures related to the conduct of the required audits. The conditions noted in this finding were previously reported in findings 2021-051 and 2020-049. Completion Date: Estimated December 2023 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

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Finding 19715 (2022-059)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

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

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 $0...

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 $0 Status: Corrective action complete Corrective Action: The Department concurs with the finding. As of June 2022, individual providers are no longer contracted through the Department and now contract with Consumer Direct of Washington. As a result of this change, this type of error will not occur for individual providers moving forward. As of March 2023, the Department reviewed all providers in the monthly exclusion report. The Department verified that the provider identified in the finding for missing enrollment documentation was never employed and did not receive any payments. Completion Date: March 2023 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

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Finding 19714 (2022-058)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Special Tests & Provisions Procurement, Suspension & Debarment

Finding: The Department of Social and Health Services did not have adequate internal controls over False Claims Act requirements. 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:...

Finding: The Department of Social and Health Services did not have adequate internal controls over False Claims Act requirements. 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 concurs with the finding. As of April 2023, the Department: ? Generated and tested a new internal report that will include all Aging and Long-Term Support Administration and Developmental Disabilities Administration Medicaid providers. ? Mailed correspondence to the one provider who was missing documentation to request the False Claims Act (FCA) attestation, policy, and procedures. ? Updated process to include follow up with providers monthly until the FCA attestations and other documents are received. By October 2023, the Department will ensure all outstanding FCA attestations and documents are returned to ensure compliance with the FCA requirement. Completion Date: Estimated October 2023 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

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Finding 19713 (2022-057)

Material Weakness 2022

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 requirements to ensure timely investigation of complaints of client abuse and neglect at Medicaid residential facilities. Questio...

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 requirements to ensure timely investigation of complaints of client abuse and neglect at Medicaid residential facilities. 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 not all complaint investigations were initiated within the required timeframes. However, the Department does not agree that noncompliance was due to inadequate internal controls. Residential Care Services (RCS) has effectively used current internal controls since fiscal year 2017 when we received the State Auditor?s Office Stewardship Award related to this audit area. Compliance with required complaint investigation timeframes decreased due to an increase in complaints from the previous fiscal year that were assigned for investigation. In addition, the effects of the COVID-19 pandemic increased staff vacancy rates to 24% due to exposure, illness, and staff resignation caused by vaccination mandates. By December 2023, the Department will: ? Extend the contract with Health Care Management Solutions to assist with surveys. This will allow RCS staff to return the focus to complaint investigations, complaint backlog, and compliance with required investigation timeframes. ? Condense and streamline Nursing Home Surveyor Training to enable staff to complete survey training faster than previous timeframes. ? Provide training to staff that were recently hired to fill the vacant positions to ensure compliance with investigation timeframes. The conditions noted in this finding were previously reported in finding 2021-054. Completion Date: Estimated December 2023 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

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Finding 19712 (2022-056)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Department of Social and Health Services, Developmental Disabilities Administration, did not have adequate internal controls over and did not comply with requirements to ensure Medicaid payments to supported living providers were allowable and adequately supported. Questioned Costs:...

Finding: The Department of Social and Health Services, Developmental Disabilities Administration, did not have adequate internal controls over and did not comply with requirements to ensure Medicaid payments to supported living providers were allowable and adequately supported. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $237,404,150 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The Department performed payment reconciliations, cost report reviews, and settlement assessments for all 140 cost reports received during the first half of fiscal year 2022 (July 1, 2021, through December 31, 2021). Of the cost reports received, 66 providers (47 percent) were subject to the Developmental Disabilities Administration (DDA) payroll verification review. The State Auditor?s Office (SAO) did not question any of the costs that were associated with the 66 providers. However, SAO is questioning all payments made to the 74 providers who did not receive a payroll verification review in the first half of the fiscal year. For the second half of the fiscal year (January 1, 2022, through June 30, 2022), even though the Department had the same internal controls in place, SAO asserted that every payment during this time frame was a questioned cost because the cost reports for calendar year 2022 had not yet been submitted for department review. The Department strongly disagrees that all these costs should be questioned. The Department reconciles payments on a calendar year basis, while SAO audits on a fiscal year basis and does not consider activities that fall outside of the audit period. The Developmental Disabilities Administration has numerous internal controls in place which provide sufficient assurance that the services paid for were provided. These include: ? Medicaid service verifications, ? Allowable costs payment reconciliations, ? Payroll verification processes, ? Review of rate payments and increases, ? Quality assurance reviews, ? Duplicate payment reports, ? Residential Care Services certification processes, ? Contract monitoring, ? Reconciliation processes for rates, cost reports, and settlements, ? Segregation of duties and other verification and approval processes. The Department strongly believes that its current oversight and monitoring procedures adequately confirm that services received by clients meet the certification standards for supported living providers. The Department continues its efforts to bring quality services to clients who receive habilitative residential support while following all program requirements, including reconciling the settlement amounts that were issued to providers in the cost report settlement process. Based on the information provided above, the Department maintains that the questioned costs for this audit finding are not substantiated. Unfortunately, SAO did not choose a more collaborative approach aimed at supporting the Department in its continuing quality improvement efforts. The Department continues to adjust its processes openly and appropriately as needed and remains open to partnering with SAO to resolve disagreements in this audit area and find common ground. The Department intends to send a request to the Centers for Medicare & Medicaid Services, through the audit resolution process, requesting the questioned costs reported by the SAO be rescinded. The conditions noted in this finding were previously reported in findings 2021-049, 2020-051, 2019-054, 2018-058, 2017-044, 2016-041, 2016-045, 2015-049, 2015-052, 2014-041, 2014-042, 2013-036, 2013-038 and 2012-039. The auditors determined findings 2016-041, 2015-052, 2014-041 and 2013-038 were resolved in fiscal year 2018. Completion Date: Not applicable 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 23129 Questioned Costs: $1

Finding 19652 (2022-045)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Reporting

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $412 Sta...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $412 Status: Corrective action in progress Corrective Action: The Department is strongly committed to ensuring the health, safety, and well-being of all children in care. The Department concurs with the finding and has taken the following actions: ? In September 2020, in response to the COVID-19 pandemic, the Department obtained grantor?s approval to revise the Child Care and Development Fund (CCDF) State Plan to waive the annual unannounced monitoring requirement and allowing for virtual monitoring, through September 30, 2021, but some providers were unable to participate in the virtual process resulting in monitoring visits not being conducted during state fiscal year 2022. ? In the fall of 2022, to address staff turnover issues, the Department began recruiting new staff and providing training on child care licensing rules and regulations. This included adding a new position in November 2022 to assist supervisors with onboarding and training new staff hired during the audit period. ? The Department implemented a data driven, phased in approach, to return staff to in-person field work after the COVID-19 pandemic: o In July 2022, began authorizing staff, subject to pandemic related restrictions, to visit providers on-site to provide assistance with meeting health and safety requirements. o In the spring of 2023, prioritized monitoring visits to return to compliance with CCDF health and safety requirements. ? Established an overpayment for the questioned costs and referred to the Office of Financial Recovery for collection. ? For license-exempt family, friend, and neighbor (FFN) providers, the Department: o Requested approval from the Office of Child Care for a hybrid monitoring approach (in-person and virtual visits). o Dedicated staff resources to update WA Compass to include all health and safety requirements for FFNs and address data format issues. The Department will continue to strengthen internal controls as follows: For licensed providers: ? Continue to implement return to in-person field work by reducing pandemic level requirements. ? Prioritize new staff training to first focus on monitoring visits and health and safety requirements. ? Continue to track and monitor health and safety requirements with available tools until all WA Compass system development is completed. ? Create an in-training licensing position to assist staff recruitment efforts and add additional lead worker positions to assist supervisors with training and caseload management. ? Conduct a root cause analysis to determine other underlying causes for missed monitoring visits and untimely follow-ups, and how to address them. ? Examine ways to secure resources to add additional full-time staff to support caseload needs. For FFN providers: ? Continue to track and monitor FFN health and safety requirements with available tools until all WA Compass system development is completed. The conditions noted in this finding were previously reported in findings 2021-039, 2020-042, 2019-039, 2018-035, 2017-025, 2016-022 and 2015-024. Completion Date: Estimated July 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 23129 Questioned Costs: $1

Finding 19651 (2022-044)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

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. For the fiscal year 2021 program audit, the State Auditor?s Office (SAO) issued a finding with $32 questioned costs for non-compliance with the CCDF eligibility requirement. No other findings, management letters, or exit items were reported in this compliance area or the cost allocation of funds based on eligibility. Given that eligibility or cost allocation has not been an area of concern, and transfers were processed between CCDF source of funds with the same eligibility criteria, the Department is assured that CCDF funding was spent appropriately within federal regulations. The Department is committed to improving internal controls. The Department does not currently have the 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 prior year?s audit recommendations, the Department has submitted a budget request to the Legislature in the 2023-2025 biennial budget for additional resources to process adjustments to include transaction-level data. As part of the audit resolution process, the Department of Health and Human Services (HHS), which oversees the CCDF program at the federal level, reviews all SAO findings and issues management decision letters. The letters will reflect the grantor?s determination of whether an audit finding is sustained, the reasons for the decision, and the required actions by the auditee. When a management decision is issued for the fiscal year 2021 finding, the Department will work with HHS and follow the audit resolution process. The conditions noted in this finding were previously reported in finding 2021-038. Completion Date: Agency Contact: Estimated December 2024 Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

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Finding 19650 (2022-043)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with period of performance requirements for the Child Care and Development Fund. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $0 Status: C...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with period of performance requirements for the Child Care and Development Fund. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $0 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. For the fiscal year 2021 program audit, the State Auditor?s Office (SAO) issued a finding with $32 questioned costs for non-compliance with the CCDF eligibility requirement. No other findings, management letters, or exit items were reported in this compliance area or the cost allocation of funds based on eligibility. Given that eligibility or cost allocation has not been an area of concern, and transfers were processed between CCDF source of funds with the same eligibility criteria, the Department is assured that CCDF funding was spent appropriately within federal regulations. The Department is committed to improving internal controls. The Department does not currently have the 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 prior year?s audit recommendations, the Department has submitted a budget request to the Legislature in the 2023-2025 biennial budget for additional resources to process adjustments to include transaction-level data. As part of the audit resolution process, the Department of Health and Human Services (HHS), which oversees the CCDF program at the federal level, reviews all SAO findings and issues management decision letters. The letters will reflect the grantor?s determination of whether an audit finding is sustained, the reasons for the decision, and the required actions by the auditee. When a management decision is issued for the fiscal year 2021 finding, the Department will work with HHS and follow the audit resolution process. The conditions noted in this finding were previously reported in finding 2021-037 and 2020-041. Completion Date: Estimated December 2024 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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Finding 19649 (2022-042)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with matching, level of effort, and earmarking requirements for the Child Care and Development Fund Cluster. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 9...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with matching, level of effort, and earmarking 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. For the fiscal year 2021 program audit, the State Auditor?s Office (SAO) issued a finding with $32 questioned costs for non-compliance with the CCDF eligibility requirement. No other findings, management letters, or exit items were reported in this compliance area or the cost allocation of funds based on eligibility. Given that eligibility or cost allocation has not been an area of concern, and transfers were processed between CCDF source of funds with the same eligibility criteria, the Department is assured that CCDF funding was spent appropriately within federal regulations. The Department is committed to improving internal controls. The Department does not currently have the 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 prior year?s audit recommendations, the Department has submitted a budget request to the Legislature in the 2023-2025 biennial budget for additional resources to process adjustments to include transaction-level data. As part of the audit resolution process, the Department of Health and Human Services (HHS), which oversees the CCDF program at the federal level, reviews all SAO findings and issues management decision letters. The letters will reflect the grantor?s determination of whether an audit finding is sustained, the reasons for the decision, and the required actions by the auditee. When a management decision is issued for the fiscal year 2021 finding, the Department will work with HHS and follow the audit resolution process. The conditions noted in this finding were previously reported in findings 2021-036 and 2020-040. Completion Date: Estimated December 2024 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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Finding 19648 (2022-041)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Matching / Level of Effort / Earmarking Subrecipient Monitoring

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure payments to child care providers for the Child Care and Development Fund Cluster programs were allowable and properly supported. Questioned Costs: A...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure payments to child care providers for the Child Care and Development Fund Cluster programs were allowable and properly supported. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $260,552,979 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. For the fiscal year 2021 program audit, the State Auditor?s Office (SAO) issued a finding with $32 questioned costs for non-compliance with the CCDF eligibility requirement. No other findings, management letters, or exit items were reported in this compliance area or the cost allocation of funds based on eligibility. Given that eligibility or cost allocation has not been an area of concern, and transfers were processed between CCDF source of funds with the same eligibility criteria, the Department is assured that CCDF funding was spent appropriately within federal regulations. The Department is committed to improving internal controls. The Department does not currently have the 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 prior year?s audit recommendations, the Department has submitted a budget request to the Legislature in the 2023-2025 biennial budget for additional resources to process adjustments to include transaction-level data. As part of the audit resolution process, the Department of Health and Human Services (HHS), which oversees the CCDF program at the federal level, reviews all SAO findings and issues management decision letters. The letters will reflect the grantor?s determination of whether an audit finding is sustained, the reasons for the decision, and the required actions by the auditee. When a management decision is issued for the fiscal year 2021 finding, the Department will work with HHS and follow the audit resolution process. The conditions noted in this finding were previously reported in findings 2021-033, 2020-038, 2019-035, 2018-034, 2017-024, 2016-021, 2015-023, 2014-023, 2013-016, 12-28, 11-23, 10-31, 9-12 and 8-13. Completion Date: Estimated December 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 23129 Questioned Costs: $1

Finding 19633 (2022-025)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding: The Office of Superintendent of Public Instruction did not have adequate controls over and did not comply with requirements to ensure it met the earmarking requirements for the Special Education program. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 Amount $18...

Finding: The Office of Superintendent of Public Instruction did not have adequate controls over and did not comply with requirements to ensure it met the earmarking requirements for the Special Education program. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 Amount $188,873 Status: Corrective action complete Corrective Action: When the Special Education program underwent a fiscal leadership transition in 2021, the incoming director identified necessary changes in agency procedures for closing out the fiscal year for the program. Since that time, the Office has fully implemented internal controls to ensure spending plans do not exceed the maximum allowable amounts earmarked for administration and other state-level activities. The updated procedures require the director of Operations and the budget analyst to perform the following: ? Review criteria for spending plans at the beginning of the fiscal year. ? Review the Grant Award Notice and Grants to States Summary Table and Preschool Grants to States Summary Table. ? Review spending plans and update the maximum allowable amounts earmarked for administration and other state-level activities in the spending plan throughout the fiscal year. ? Meet weekly to review spending plans and update plans as requests are received. ? Review monthly expenditure reports during weekly meetings. These updated procedures have contributed to increased communication and partnership between the director of Operations and the budget analyst. These internal controls provide assurance that maximum allowable amounts earmarked for administration and other state-level activities will be in compliance with federal rules. The Office will consult with the federal grantor to discuss whether the questioned costs identified in the audit should be repaid. Completion Date: March 2023 Agency Contact: Tania May Assistant Superintendent, Special Education PO Box 47200 Olympia, WA 98504-7200 (360) 725-6075 tania.may@k12.wa.us

View Audit 23129 Questioned Costs: $1

Finding 19624 (2022-007)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303 § 200.328

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with requirements to ensure it submitted complete and accurate quarterly performance reports for the Workforce Innovation and Opportunity grant. Questioned Costs: Assistance Listing # ...

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with requirements to ensure it submitted complete and accurate quarterly performance reports for the Workforce Innovation and Opportunity grant. Questioned Costs: Assistance Listing # 17.258 17.259 17.278 Amount $0 Status: Corrective action in progress Corrective Action: In response to the finding, the Department is in the process of developing a comprehensive system and set of protocols to strengthen internal controls over the completion and submission of quarterly performance reports for the Workforce Innovation and Opportunity Act (WIOA) grant. The Department: ? Executed a Workforce Integrated Technology Replacement Project that focuses on improving case management and data management internal controls. The Department estimates the project will be completed by December 2024. ? Initiated and is in the process of a statewide implementation of the U.S. Department of Labor (DOL) Quarterly Report Analysis data integrity and data quality internal controls system. The Department will: ? Continue to execute the Data Element Validation policy update for the Participant Individual Record Layout (PIRL) report per DOL expectations. ? Continue to provide technical assistance, training, and one-on-one coaching for the local areas, which cover WIOA Title I and WIOA Title III, PIRL reporting, data management, validation, quality, and integrity systems and processes. The conditions noted in this finding were previously reported in findings 2021-007 and 2020-012. Completion Date: Estimated December 2024 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 23129

Finding 19617 (2022-003)

Significant Deficiency 2022

State of Washington C/o Office of Financial Management

WA

School Nutrition Programs Subrecipient Monitoring Equipment & Real Property Management

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over accountability for USDA-donated foods. Questioned Costs: Assistance Listing # 10.553 10.555 10.555 COVID-19 10.556 10.559 10.582 Amount $0 Status: Corrective action in progress Correc...

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over accountability for USDA-donated foods. Questioned Costs: Assistance Listing # 10.553 10.555 10.555 COVID-19 10.556 10.559 10.582 Amount $0 Status: Corrective action in progress Corrective Action: The Office has taken the following corrective action to strengthen internal controls over accounting for USDA-donated foods: ? Reviewed current process for monthly inventory. ? Reviewed process for inventory discrepancies follow up. ? Implemented a process for documenting follow-up efforts. The Office is following the USDA requirements for conducting annual inventory and reconciliation in June of each year. In addition, the Office has contracted with a vendor for a new and updated Food Distribution Management System. The current timeline for system launch is as follows: ? November 2023 ? Data migration and system set up ? February 2024 ? Survey period ? August 2024 ? Ordering of food, receiving, and inventory management The conditions noted in this finding were previously reported in findings 2021-003, 2020-004 and 2019-005. Completion Date: Estimated July 2023 Agency Contact: Leanne Eko Chief Nutrition Officer PO Box 47200 Olympia, WA 98504-7200 (360) 725-0410 leanne.eko@k12.wa.us

View Audit 23129

Finding 19554 (2022-022)

None 2022

State of Washington C/o Office of Financial Management

WA

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles § 200.1 § 200.410 § 200.516

Finding: Washington State University did not ensure that returns of Title IV funds were accurate for the Student Financial Assistance programs. Questioned Costs: Assistance Listing # 84.007 84.033 84.038 84.063 84.268 84.379 Amount $2,582 Status: Corrective action complete Corrective Act...

Finding: Washington State University did not ensure that returns of Title IV funds were accurate for the Student Financial Assistance programs. Questioned Costs: Assistance Listing # 84.007 84.033 84.038 84.063 84.268 84.379 Amount $2,582 Status: Corrective action complete Corrective Action: The University has improved processes for the return of Title IV funds. The University: ? Included a standard calculation in workbooks to quickly identify whether amounts to be returned for withdrawn students will exceed the amounts disbursed. ? Implemented a quality check to review these exceptions, and to investigate and correct as necessary. The University has returned all questioned costs to the sponsors. Completion Date: May 2023 Agency Contact: Heather Lopez Chief Audit Executive PO Box 641221 Pullman, WA 99164-1221 (509) 335-2001 hlopez@wsu.edu

View Audit 23129 Questioned Costs: $1

Finding 16717 (2022-002)

Significant Deficiency 2022

Henry County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance § 200.1 § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Debra G. Walker Contact Phone Number: 765-529-2800 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: We have corrected and added the $47,363 to the expenditure report. Anticipated Comp...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Debra G. Walker Contact Phone Number: 765-529-2800 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: We have corrected and added the $47,363 to the expenditure report. Anticipated Completion Date: Corrected on the March 2023 expenditure report.

View Audit 21367

Finding 16663 (2022-023)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with federal requirements to ensure Local Education Agencies implemented testing security measures. Questioned Costs: Assistance Listing # 84.010 Status: Corrective ac...

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with federal requirements to ensure Local Education Agencies implemented testing security measures. Questioned Costs: Assistance Listing # 84.010 Status: Corrective action in progress Corrective Action: The Office monitors and ensures all Local Education Agencies (LEA) implement school testing security measures. All LEAs are required to submit a District Administration and Security Report (DASR) at the conclusion of the testing cycle to document the security training and that protocols have been followed. The Office will continue to communicate with LEAs to ensure they provide the DASR for all tests administered in the spring, as follows: ? Once per week for four weeks leading up to the end of the test administration window. ? Once per week for three weeks after the end of the test administration window. In August, the Office will receive the annual final list of all tests administered by each LEA and will be able to narrow its focus for sending out weekly reminders. If the Office has not received completed DASRs by mid-September, a management decision letter will be sent to the LEA?s Superintendent to inform them of the non-compliance and potential consequences as outlined in federal regulations. The conditions noted in this finding were previously reported in findings 2021-021 and 2020-026. Completion Date: Estimated October 2023 Agency Contact: Christopher Hanczrik Director, Assessment Operations and Select Assessments PO Box 47200 Olympia, WA 98504-7200 (360) 485-3580 Christopher.Hanczrik@k12.wa.us

View Audit 23129

Finding 16551 (2022-002)

Material Weakness 2022

City of Sandusky

OH

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.328 § 200.329

All federal Project and Expenditure reports were filed timely and all actual expenditures were also reported correctly according to the report overview page. This finding deals with the body of the report which incorrectly listed the Justice Center Project twice, with the obligation amount of $880,0...

All federal Project and Expenditure reports were filed timely and all actual expenditures were also reported correctly according to the report overview page. This finding deals with the body of the report which incorrectly listed the Justice Center Project twice, with the obligation amount of $880,00 listed for the project. This duplicated project has been removed from future reports. The finding noted for $175,741, once again has all the correct totals in project overview report, which should be the summation of the report. We have been rehiring staff with American Rescue Plan funds since 2021, and this has been an ongoing project. Once again, the report overview page lists the correct expenditures, however the body of the report has the project listed twice. This duplicated project has been removed from future reports. The reporting software gives a total of expenditures before you hit submit on each report, this total has always displayed the correct cumulative expenditure total. If projects were entered twice, the total expenditures should of been over by these dollar amounts, and they were not.

View Audit 21781

Finding 16542 (2022-001)

Significant Deficiency 2022

Lehigh Valley Dual Language Charter School

PA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finding No. 2022-001 (Cost Segregation) Condition: The Charter School does not segregate federal grant expenditures within the accounting software instead choosing to track the expenditures for each grant in excel. During our audit, we found inconsistencies with where expenditures were reported in t...

Finding No. 2022-001 (Cost Segregation) Condition: The Charter School does not segregate federal grant expenditures within the accounting software instead choosing to track the expenditures for each grant in excel. During our audit, we found inconsistencies with where expenditures were reported in the excel spreadsheet and where they were recorded in the software. Recommendation: We recommend the School utilize a more appropriate software for fund accounting that will allow for the segregation of federal grant expenditures directly in the software using a distinct source code for each grant in accordance with the PDE Chart of Accounts. Corrective Action: Effective July 1, 2022, the School?s general ledger was transitioned from Intuit QuickBooks to Sage Intacct. Sage Intacct provides a more robust chart of accounts using a string of dimension codes which allows for detailed grant expenditure and revenue tracking; including details related to departments/ functions, funds, and both the accrual basis and modified accrual basis of accounting. We believe the new accounting system and chart of accounts will allow for the proper segregation of federal grant expenditures directly in the general ledger in accordance with the PDE Chart of Accounts. Person Responsible: Elsie Perez, CEO Proposed Completion Date: July 1, 2022

View Audit 20450

Finding 16525 (2022-004)

Significant Deficiency 2022

Foster-Glocester Regional School District

RI

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.430

Finding: 2022-004 Corrective Action Plan: The District?s payroll process is significantly lacking proper control procedures. With the hiring of a new financial manager, policies, procedures and controls will be implemented immediately, including the proper tracking of time and effort for employees...

Finding: 2022-004 Corrective Action Plan: The District?s payroll process is significantly lacking proper control procedures. With the hiring of a new financial manager, policies, procedures and controls will be implemented immediately, including the proper tracking of time and effort for employees charged to federal grants as required. Anticipated Completion Date: September 1, 2023 Contact Person: Amanda Raymond, Director of Finance

View Audit 20393

Finding 16504 (2022-002)

Material Weakness 2022

Grand Rapids Christian Schools

MI

Allowable Costs / Cost Principles Procurement, Suspension & Debarment School Nutrition Programs § 200.302 § 200.305 § 200.317 § 200.320 § 200.326

#2022-002: Material Weakness in Controls over Compliance: Administrative Requirements of Uniform Guidance -Administrative Policies Recommendations: Grand Rapids Christian Schools should consider the following written policy additions or updates: ? Financial Management (2 CFR 200.302) The financial m...

#2022-002: Material Weakness in Controls over Compliance: Administrative Requirements of Uniform Guidance -Administrative Policies Recommendations: Grand Rapids Christian Schools should consider the following written policy additions or updates: ? Financial Management (2 CFR 200.302) The financial management policy should include records documenting compliance, and the tracking of funds to determine that expenditures are in accordance with the terms and conditions of the federal awards. The financial management and reporting system must provide the following : ? Identification - Title of the award, CFDA number ? Complete disclosure of accurate and current financial results of each federal award ? Source and application of funds for federal award activity ? Record retention and access - define the time period for which records must be kept (can vary by grant agreement), and who has the ability access the records (?200.333 - ?200.337) ? Written procedure to implement cash management requirements (see below) ? Written procedures for determining the allowability of costs (see below) ? Cash Management (2 CFR 200.305) A written policy is required by Uniform Guidance detailing the Organization's procedures to minimize the time that elapses between draw and expenditure of federal dollars. ? Allowable Costs (2 CFR 200.302(b)(7)) The Organization must have written procedures for determining the allowability of costs in accordance with Subpart E - Cost Principles of Uniform Guidance and the terms and conditions of the Federal award. This includes the determination of allowable costs and the review of this determination. The standard assumes policies and procedures are in place for disbursements, and the allowable cost policy will demonstrate how the Organization ensures compliance. The criteria for costs to be considered allowable are documented within 2 CFR 200.403. ? Procurement Standards (2 CFR 200.317 - 200.326) The Organization must have a written policy that promotes full and open vendor competition, conflict of interest policies should cover employees as well as the organization, and general purchase requirements with specific thresholds as set forth by the Uniform Guidance. There are five allowable procurement methods as described in ?200.320, depending upon the dollar value of the purchase or contract. Views of Responsible Officials and Planned Corrective Actions: ? Grand Rapids Christian Schools follows procurement and record retention standards provided by the USDA. ? GRCS does not have actual written policies and procedures for Financial Management, Cash Management, Allowable Costs, and Procurement Standards, but do have practices in place to follow USDA guidelines. In the case of cash management, the only location that takes cash is GRCHS. In that instance, along with Meal Magic, cash registers are zeroed out and balanced to Meal Magic and cash deposits are made daily. ? GRCS Business Office will work with the Food Service Director to begin formulating written policies and procedures specific to Grand Rapids Christian Schools. GRCS will utilize the resources from Uniform Guidance and Code of Federal Regulations (CFR) to develop policies that are compliant with those requirements prior to June 30, 2023.

View Audit 20389

Finding 16394 (2022-005)

None 2022

Benzie County Central School District

MI

Allowable Costs / Cost Principles § 200.430

Finding Number 2022-005 Education Stabilization Fund: Elementary and Secondary School Emergency Relief (ESSER) Assistance Listing Number 84.425D Allowable Costs/Cost Principles ? Documentation of Employee Time and Effort Immaterial Noncompliance Criteria: Per Federal regulations 2 CFR section 200.43...

Finding Number 2022-005 Education Stabilization Fund: Elementary and Secondary School Emergency Relief (ESSER) Assistance Listing Number 84.425D Allowable Costs/Cost Principles ? Documentation of Employee Time and Effort Immaterial Noncompliance Criteria: Per Federal regulations 2 CFR section 200.430(i)(1)(vii), the School District must maintain time and effort distribution records for an employee who works in part on the consolidated administrative cost objective and in part on a federal program whose administrative funds have not been consolidated or on activities funded from other revenue sources. Condition: The School District did not maintain time and effort distribution records for employees who were partially funded with ESSER Federal funds. Cause: Oversight. Effect: Time and effort reports were not completed. Questioned Costs: None. Recommendation: Time and effort reports should be completed throughout the year listing the employees name, position or job title, and percentage of time spent on each Federal award and signed by the employee?s supervisor. Management's Response and Corrective Actions: The Director of Finance and Superintendent completed time and effort reports for the ESSER funds expended for fiscal year ending June 30, 2022 and will continue to complete time and effort reports going forward. Person Responsible for Corrective Action: Justin Weston, Director of Finance, and Amiee Erfourth, Superintendent Completion Date: November 21, 2022.

View Audit 22357

Finding 16316 (2022-002)

Significant Deficiency 2022

Chisholm School District I-42

OK

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Reference Number: 22-02 Name of Award ? Project Number (794, 628, 770) (Federal Findings) Condition/Finding: The District's final expenditure reports with the Oklahoma State Department of Education and Oklahoma Cost Accounting System (OCAS), did not match the actual allowable expense for their p...

Reference Number: 22-02 Name of Award ? Project Number (794, 628, 770) (Federal Findings) Condition/Finding: The District's final expenditure reports with the Oklahoma State Department of Education and Oklahoma Cost Accounting System (OCAS), did not match the actual allowable expense for their program. Three programs (794, 628, 770) had OCAS coding errors when final reports were submitted to the Oklahoma State Department of Education. Corrective steps that have already been implemented and/or the steps that will be implemented: All OCAS data, both receiving and expenditures, will be correct and accurate. All OCAS data involving Federal Programs will be reported correctly and accurately to the Oklahoma State Department of Education. Completion Date: Immediately The plan for monitoring adherence to the corrective action plan: All Chisholm Public Schools central office personnel involved with purchase orders, and OCAS data, will seek professional development and training to improve professionally. Additionally, all Chisholm Public Schools central office personnel will work collaboratively to ensure that all OCAS data is correct and accurate on an ongoing basis. Finally, all finalized OCAS data will be completely accurate when submitting to the Oklahoma State Department of Education. If warranted, reasons why the district does not consider a Corrective Action necessary. Superintendent's Signature Date

View Audit 21640

Finding 16244 (2022-001)

Significant Deficiency 2022

Northkey Community Care

KY

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

Northern Kentucky Mental Health ? Mental Retardation Regional Board, Inc. agrees with the finding and will complete necessary training with program employees regarding organizations established and required procedures along with the necessity of these procedures and the additional importance due to ...

Northern Kentucky Mental Health ? Mental Retardation Regional Board, Inc. agrees with the finding and will complete necessary training with program employees regarding organizations established and required procedures along with the necessity of these procedures and the additional importance due to federal program requirements.

View Audit 22999

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