Corrective Action Plans

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Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (superintendent) compares the meal counts in the claim to the SDS daily meal co...
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (superintendent) compares the meal counts in the claim to the SDS daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimbursement rates. The reviewer will then sign and date a reconciliation sheet before submission. Management Response: The corrective action plan was discussed with the employee responsible for filing the claim, the business manager, and the superintendent. After discussion, the plan was approved by the superintendent.
2025--004 US Department of Education Material Weakness in Internal Control over Compliance and Other Matter Cash Management Auditor's Recommendation: One City Schools, Inc. should implement appropriate internal controls for reviewing funding claims prior to submission. Corrective Action: One City ad...
2025--004 US Department of Education Material Weakness in Internal Control over Compliance and Other Matter Cash Management Auditor's Recommendation: One City Schools, Inc. should implement appropriate internal controls for reviewing funding claims prior to submission. Corrective Action: One City adopted a new grants management process which requires that all submitted claims are reviewed and signed by two responsible officials. Evidence of approvals will be maintained in the electronic grant files. In addition, One City has developed a training tool so that all staff who have grant claiming authority must participate in the training. The new Chief Financial Officer will monitor compliance with the policy and ensure proper documentation exists. Responsible for Corrective Action: Scott R Haumersen CPA, CGMA Shaumersen@onecityschools.org 608-575-4950 Anticipated Completion Date: June 30th, 2026
Corrective Action Plan 2025-003: Student Financial Aid and Accounts Receivable will work in coordination to sync the process of importing files and posting to accounts on the same day. Our new ERP has streamlined reporting to COD and catches and corrects any date discrepancies between the two system...
Corrective Action Plan 2025-003: Student Financial Aid and Accounts Receivable will work in coordination to sync the process of importing files and posting to accounts on the same day. Our new ERP has streamlined reporting to COD and catches and corrects any date discrepancies between the two systems. This finding was directly related to the migration from our old system and the disruption of data flow. Additionally, a review for matching COD disbursement dates will now be included during the monthly reconciliation process moving forward as a second layer of quality control. Anticipated Completion Date: June 30, 2026 Contact Person: Mary Reed, Director of Financial Aid & Advising
Finding No.: 2025-003 – Disbursements Reporting Federal Agency: U.S. Department of Education Program Name: Student Financial Assistance Cluster – Pell Grant Program and Federal Direct Loan (FDL) Program ALN Number: 84.063, 84.268 Federal Award Year: July 1, 2024 – June 30, 2025 Criteria Institutions...
Finding No.: 2025-003 – Disbursements Reporting Federal Agency: U.S. Department of Education Program Name: Student Financial Assistance Cluster – Pell Grant Program and Federal Direct Loan (FDL) Program ALN Number: 84.063, 84.268 Federal Award Year: July 1, 2024 – June 30, 2025 Criteria Institutions submit Direct Loan, Pell Grant, TEACH Grant, and IASG origination records and disbursement records to the COD system. Origination records can be sent well in advance of any disbursements, as early as the institution chooses to submit them for any student the institution reasonably believes will be eligible for a payment. An institution follows up with a disbursement record for that student no earlier than (1) seven calendar days prior to the disbursement date under the Advance or Heightened Cash Monitoring 1 payment methods, or (2) the date of the disbursement under the Reimbursement or Heightened Cash Monitoring 2 Payment Method. The disbursement record reports the actual disbursement date and the amount of the disbursement. ED processes origination and/or disbursement records and returns acknowledgments to the institution. The acknowledgments identify the processing status of each record: Rejected, Accepted with Corrections, or Accepted. In testing the origination and disbursement data, the auditor should be most concerned with the data ED has categorized as accepted or accepted with corrections. Institutions must report student disbursement data within 15 calendar days after the institution makes a disbursement or becomes aware of the need to make an adjustment to previously reported student disbursement data or expected student disbursement data. Institutions may do this by reporting once every 15 calendar days, bi-weekly or weekly, or may set up their own system to ensure that changes are reported in a timely manner. Title 2 U.S. Code of Federal Regulations Part 200 (2CFR 200) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, section 303(a) states, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statues, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Conditions Found For two (2) out of 69 Pell COD Reports selected for test work, the required Pell student payment data was reported to the Common Origination and Disbursement (COD) website 52 days after disbursement, which exceeds the 15-day timeframe required by federal regulations. For one (1) out of 69 Pell COD Reports selected for test work, the required Pell student payment data was reported to the Common Origination and Disbursement (COD) website 261 days after disbursement, which exceeds the 15-day timeframe required by federal regulations. For four (4) out of 69 Pell COD Reports and three (3) out of 113 FDL COD Reports selected for test work, the Cost of Attendance was misreported to the COD website. There was no follow-up by the University to correct the discrepancies. For ten (10) out of 69 Pell and ten (10) out of 113 FDL COD Reports selected for test work, the transaction number did not agree between the FASFA Submission Summary Form and the COD website. Cause The cause of the conditions found is insufficient review to ensure that accurate disbursement reporting is occurring on a timely basis, all records submitted to COD were accepted, and, for those that were rejected, that corrected data is submitted within the required timeframe. Possible Asserted Effect The possible effect of the condition found is that the University may not be reporting Pell and FDL disbursements to COD completely, accurately, and in a timely manner. Questioned Costs No questioned costs were identified. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes; 2024-002 Views of Responsible Officials Management accepts this finding and notes several issues that affected the submissions including staffing onboarding and training, submission review, and deadline controls. Management continues to fill positions experiencing unexpected turnover and to improve training for current and newly hired staff in order to restore adequate staffing levels and ensure continuity of COD reporting responsibilities. From May through September 2025, management retained Blue Icon Advisors (BIA) to provide dedicated coaching and support for improved onboarding and compliance knowledge, including providing specialized training to the Loan Manager relative to federal regulations and proper loan record management. Management is implementing processes to improve the weekly review and update of Cost of Attendance (COA) information and CPS transaction numbers to further ensure institutional records are aligned with COD data and to reduce the risk of mismatched records. Management has also strengthened internal controls with improvements to processes which enhance the monitoring of submission deadlines, review of file acceptance reports, and identification and correction of electronic records issues prior to submission. These improvements include the increased and more effective utilization of COD-delivered reports (including Pell Reconciliation and Anticipated Disbursement Reports) and institutional and PeopleSoft reports and queries, with reviews conducted on a weekly basis to promptly identify record discrepancies requiring resolution. Anticipated Completion Date March 2026 - completed Responsible Person Nicole Adner, Director of Financial Aid
Child Nutrition Cluster, ALN’s 10.553 & 10.555 Recommendation: We recommend the review and approval process over monthly claims for reimbursement be strengthened to enhance the prevention of discrepancies between the claim for reimbursement and underlying data. Explanation of disagreement with audit...
Child Nutrition Cluster, ALN’s 10.553 & 10.555 Recommendation: We recommend the review and approval process over monthly claims for reimbursement be strengthened to enhance the prevention of discrepancies between the claim for reimbursement and underlying data. Explanation of disagreement with audit finding: Management agrees with the finding. Action taken in response to finding: Newton operated the National School Lunch Program (NSLP) during the Extended School Year (ESY) for the first time during the summer 2024, which created a reporting challenge. Students from across the district's 23 schools attended ESY in seven (7) schools/sites, but their school-year home schools could not be changed in the Student Information System (Aspen). Therefore, student meal counts reported to their home school on the FP9 but had to be reported on the DESE School Report for the ESY school/site they attended. Given the system interface complexities, some counts had to be manually entered, for which two (2) meal counts were incorrectly entered for breakfast versus lunch. Given that the district did not operate the School Breakfast Program (SBP) and did not serve breakfast, these two (2) manual errors were counted as lunch counts when entered for the School Report. The total meal count did match on the FP9 and School Report. For this inconsistency, the correct action should have been to manually update these two counts in the Point of Sale system (Mosaic) so that the two breakfast counts reflected correctly as lunch counts. Name(s) of the contact person(s) responsible for corrective action: Amy Mistrot, NPS Director of Business Operations. Planned completion date for corrective action plan: Newton was able to set conditional parameters in Aspen for ESY 2025 so that the student meal counts reported to their ESY school/site versus their home school, so this reporting issue was corrected the following summer.
Condition: The District's expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of the report. Plan: Management will review all expenditure reports. Only expenditures obligated within the grant period wi...
Condition: The District's expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of the report. Plan: Management will review all expenditure reports. Only expenditures obligated within the grant period will be included on the expenditure report. Any obligations not yet liquidated will be reported as such.
Finding No. 2025-006 ALN No. 11.419 Program Title: Hawaii Coastal Zone Management Program Grant Award No.: NA22NOS4190022 NA23NOS4190139 NA24NOSX419C0023 NA22NOS4190065 Condition Accuity noted that for various samples, the time between drawdown and disbursement of federal funds was up to 266 days el...
Finding No. 2025-006 ALN No. 11.419 Program Title: Hawaii Coastal Zone Management Program Grant Award No.: NA22NOS4190022 NA23NOS4190139 NA24NOSX419C0023 NA22NOS4190065 Condition Accuity noted that for various samples, the time between drawdown and disbursement of federal funds was up to 266 days elapsed. Indicating that cash management controls were not operating to minimize the time between transfer and disbursement. Corrective Action Plan OPSD DBEDT will ensure that program personnel are familiar with all federal requirements, including ensuring that funds are disbursed timely. Person Responsible Mary Alice Evans, Director of Office of Planning and Sustainable Development Anticipated Date of Completion April 1, 2026
Finding No. 2025-005 ALN No. 10.179 Program Title: Micro-Grants Food Security Program Grant Award No.: AM200100XXXG132 21MGFSPHI1003-00 AM22MGFSPHI1007-04 23MGFSPHI1011-00 24MGFSPHI1016-00 Condition An elapsed time of 583 days between the drawdown and disbursement date of funds for the program and t...
Finding No. 2025-005 ALN No. 10.179 Program Title: Micro-Grants Food Security Program Grant Award No.: AM200100XXXG132 21MGFSPHI1003-00 AM22MGFSPHI1007-04 23MGFSPHI1011-00 24MGFSPHI1016-00 Condition An elapsed time of 583 days between the drawdown and disbursement date of funds for the program and that the check date of 01/24/2025 occurred after the grant period expiration of 09/29/2024. Indicating that cash management controls were not operating to minimize time between transfer and disbursement and that the period of performance was unauthorized to be extended past the budget date. Corrective Action Plan Concur. The Hawaii Department of Agriculture and Biosecurity (DAB) will change administrative procedures for drawdown and disbursement of federal funds under the Micro-Grants Food Security Program. DAB will process the grant contracts and payments in batches of about 100 micro-grants per month, and federal drawdown will not occur until about a batch of 100 contracts have been executed. Additional staff hired for grant processing will expedite the payment process to ensure conformity with the 25-day disbursement timeline. Person Responsible Brendan Akamu, Market Development Branch Manager Anticipated Date of Completion Corrective action plan will be implemented in April 2026.
Matching (Significant Deficiency in Internal Control and Noncompliance) Assistance Listings number and program name: COVID-19 93.354 Public Health Emergency Recommendation: The County should establish procedures to track matching requirements in the general ledger, ensure all in-kind contributions a...
Matching (Significant Deficiency in Internal Control and Noncompliance) Assistance Listings number and program name: COVID-19 93.354 Public Health Emergency Recommendation: The County should establish procedures to track matching requirements in the general ledger, ensure all in-kind contributions are supported by proper documentation (e.g., timesheets), and review match compliance before use of federal funds. Contact Person(s): Catrina Jenkins, Emergency Management Manager Anticipated completion date: June 30, 2026 County Discussion: Concur: In coordination with the Arizona Department of Health Services (ADHS), the County will implement procedures to ensure matching activity is properly tracked within the general ledger. The County will also ensure that all in-kind contributions are supported by appropriate documentation, such as timesheets or other relevant supporting records, in accordance with federal grant requirements. Additionally, the County will implement a review process to verify that matching requirements are properly documented and met prior to the drawdown or use of federal funds. These measures are intended to strengthen internal controls and ensure compliance with federal grant matching requirements.
Assistance to Firefighters Grant – Assistance Listing Number 97.044 Recommendation: We recommend that the Town establish and implement written procedures requiring the preparation, review, and retention of all federal grant reimbursement requests. Explanation of disagreement with audit finding: Mana...
Assistance to Firefighters Grant – Assistance Listing Number 97.044 Recommendation: We recommend that the Town establish and implement written procedures requiring the preparation, review, and retention of all federal grant reimbursement requests. Explanation of disagreement with audit finding: Management agrees with the finding. Action taken in response to finding: The Town agrees with this recommendation and has updated its grant policies and procedures accordingly. Written procedures are now in place requiring the preparation, review, and retention of all federal grant reimbursement requests. Going forward, the Finance Department will review all requests, and approval from the Town Manager will be required prior to submission. This is not expected to be an issue going forward. Name(s) of the contact person(s) responsible for corrective action: Marie Almodovar, Finance Director Planned completion date for corrective action plan: Fiscal Year 2026.
Corrective Action Plan 2025-001: Management has made the appropriate updates and communicated the URLs for its contract and cost information to the Department of Education in July 2025 for its contract with BankMobile. Management will monitor the Department of Education’s cash management contract li...
Corrective Action Plan 2025-001: Management has made the appropriate updates and communicated the URLs for its contract and cost information to the Department of Education in July 2025 for its contract with BankMobile. Management will monitor the Department of Education’s cash management contract listing and will ensure that the contract is listed once the Department of Education updates its cash management contracts database as the most recent update to the cash management contracts database published by the Department of Education listed an update date of mid-January 2024. Completion Date: July 2025 Contact Person: Joanne Rozborski, Assistant Vice President, Student Financial Services
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Federal Transit Cluster Assistance Listing Numbers: 20.507, 20.526 Contact Person: Megan Coons, Finance Director Anticipated Completion Date: March 31, 2026 Planned Corrective Action: The Authority has implemented a dual‐review process ...
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Federal Transit Cluster Assistance Listing Numbers: 20.507, 20.526 Contact Person: Megan Coons, Finance Director Anticipated Completion Date: March 31, 2026 Planned Corrective Action: The Authority has implemented a dual‐review process requiring preparation of reimbursement requests by staff and independent review and approval by a second authorized individual in a higher level management role. Reconciliations of reimbursement requests are to be completely monthly and will include detailed expenditure reports and grant agreement references to ensure requests match appropriately to Federal expenditures. Additionally, The Authority will implement mandatory training for all staff involved in grant management on Federal compliance requirements, documentation standards, and internal control procedures.
Block Grants for Prevention and Treatment of Substance Abuse (93.959) COVID-19 –Block Grants for Prevention and Treatment of Substance Abuse (93.959) State Agency: Department of Human Services Federal Agency: U.S. Department of Health and Human Services Reporting – Federal Funding Accountability and...
Block Grants for Prevention and Treatment of Substance Abuse (93.959) COVID-19 –Block Grants for Prevention and Treatment of Substance Abuse (93.959) State Agency: Department of Human Services Federal Agency: U.S. Department of Health and Human Services Reporting – Federal Funding Accountability and Transparency Act (FFATA) VIEWS OF RESPONSIBLE OFFICIALS AND CORRECTIVE ACTION PLAN The Department of Human Services, Division of Mental Health and Addiction Services (DMHAS) does not dispute the FFATA upload dates for three (3) of the thirteen (13) subawards tested, but it disputes that such uploads were untimely. One subaward was uploaded only seven (7) days late. DMHAS submits that it substantially complied, no finding should issue and no corrective action is required in that instance. The two (2) remaining awards at issue were funded with the ARPA Block Grant. On March 24, 2025, U.S. DHHS took unprecedented action and issued a notice of early termination of ARPA funding, purportedly for cause because the Covid-19 health emergency had ended. The notice of early termination and subsequent, revised Notice of Award (NOA), required DMHAS to cease all activities. It also sought to revise the original grant terms, retroactive to the original September 1, 2021 project start date. By way of example, the revised NOA also includes new conditions and certifications required to draw down federal funds. DMHAS complied with the notice of early termination and immediately ceased all activities; it stopped issuing subaward letters, it ceased all subaward uploads into its Contract Information Management System, it stopped all reimbursements, and it stopped all FFATA uploads pending or in process. Also in response to the abrupt early termination of funding, DMHAS issued “stop work” orders to all impacted agencies and advised that there was no assurance of reimbursement as of the effective date of notice. Shortly thereafter, DMHAS joined numerous other State authorities and filed a formal complaint in federal district court, alleging that the early termination was unlawful and caused the States irreparable harm. On April 5, 2025, the court entered a temporary injunction and scheduled a hearing for preliminary injunctive relief. U.S. DHHS moved for reconsideration. Several weeks later, the Court entered a preliminary injunction enjoining the enforcement of the early termination of ARPA until further order of the Court. The cessation of FFATA uploads from the March termination to the receipt of injunctive relief was necessary to: 1. Maintain strict compliance with the revised NOA terms and conditions, including the written obligation to cease all activities; 2. Maintain strict compliance with the revised NOA terms and conditions, by issuing “stop work” orders; 3. Ensuring DMHAS’s “stop work” orders were not superseded by FFATA uploads or USA.Spending publications while the request for injunctive relief was pending, so no individual or entity (including the US Office of the Attorney General, US DHHS, or subawardee) could construe the upload as renewed authority to continue to expend funds through subaward end date; 4. Fully protect the prosecution of DMHAS’s claims in the pending, federal litigation, as well as DMHAS’s defenses; and 5. Mitigate DMHAS and subawardee damages in the underlying litigation. Based on the unprecedented early termination of block grant funding and ensuing litigation, DMHAS submits that the timeline to complete FFATA uploads was stayed. Such determination is consistent with the Court’s preliminary injunction, which makes clear that U.S. DHHS immediately treat any actions taken to implement or enforce the early funding terminations, as null and void and rescinded. Therefore, DMHAS should not be issued a FFATA finding that relates directly to the revised NOAs or the direction to cease all activities, and under these extraordinary circumstances, the uploads in question should be classified as non-reportable and immaterial, with no corrective action required. COMPLETION DATE/ CONTACT PERSON & PHONE# January 1,2025 Gordon Horvath, CFO (609) 544-6817 Gordon.Horvath@dhs.nj.gov John Fogliano, Deputy CFO (609) 438-4278 John.Fogliano@dhs.nj.gov
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (Superintendent) compares the meal counts in the claim to the Skyward daily mea...
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (Superintendent) compares the meal counts in the claim to the Skyward daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimbursement rates. The reviewer will then sign and date a reconciliation sheet before submission.
Management is responsible for submitting accurate information when requesting federal funds to maintain compliance with reporting requirements. Personnel Responsible for Corrective Action: Josh Dining, Controller Anticipated Completion Date: Corrective action plan will be implemented by June 30, 202...
Management is responsible for submitting accurate information when requesting federal funds to maintain compliance with reporting requirements. Personnel Responsible for Corrective Action: Josh Dining, Controller Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2026. Corrective Action Plan – Management will update practices and implement procedures to ensure that only actual incurred costs will be included on the request for reimbursement forms on a go-forward basis.
Payroll Allocations: Criteria: Management was responsible for implementing policies and procedures to ensure salaries and wages reimbursable by the federal award are approved and submitted for reimbursement at appropriate amounts. Condition: During compliance testing, it was determined that certain ...
Payroll Allocations: Criteria: Management was responsible for implementing policies and procedures to ensure salaries and wages reimbursable by the federal award are approved and submitted for reimbursement at appropriate amounts. Condition: During compliance testing, it was determined that certain payroll expenses related to an employee whose wages are reimbursed by the federal award, were not properly allocated to the federal award. Context: Improper allocations of one employee's wages resulted in an under-allocation totaling $9,287 to the federal award during the year ended June 30, 2025. Cause: The allocation percentages were not appropriately updated in the underlying accounting system. Effect: As a result of the condition, the payroll expenses related to the federal award were under-reported during the year ended June 30, 2025. Questioned Costs: None. Repeat Finding: No. Recommendation: In the future, the System should implement appropriate processes and controls to ensure the underlying accounting system is updated timely and appropriately for changes in payroll allocations. Contact: Michael Hammond, Interim Health System Controller. Corrective Actions Taken or Planned: Management acknowledges the finding and ensure to implement appropriate processes and controls to update the system accordingly as needed.
Approval of Timecards: Criteria: Management was responsible for implementing policies and procedures to ensure salaries and wages reimbursable by the federal award are adequately documented, approved and submitted for reimbursement at appropriate amounts. Condition: During compliance testing, it was...
Approval of Timecards: Criteria: Management was responsible for implementing policies and procedures to ensure salaries and wages reimbursable by the federal award are adequately documented, approved and submitted for reimbursement at appropriate amounts. Condition: During compliance testing, it was determined that although certain timecards selected for testing did not contain inappropriate amounts, no evidence of approval was present which is a deviation in compliance with the above criteria. Context: Two out of fourteen total timecards that were selected for testing did not contain evidence of approval. Cause: The appropriate level of management did not approve the timecards. Effect: As a result of the condition, two out of fourteen total timecards that were selected for testing did not contain evidence of approval. Questioned Costs: None. Repeat Finding: No. Recommendation: In the future, the System should implement appropriate processes and controls to ensure all timecards are approved by the appropriate level of management. Contact: Michael Hammond, Interim Health System Controller. Corrective Actions Taken or Planned: Management acknowledges the finding and will ensure all timecards are approved in the future.
Finding 2025-103: Cash Management - Criteria: The recipient must: establish, document, and maintain effective internal control over the federal award that provides reasonable assurance that the recipient is managing the federal award in compliance with federal statutes, regulations, and terms and co...
Finding 2025-103: Cash Management - Criteria: The recipient must: establish, document, and maintain effective internal control over the federal award that provides reasonable assurance that the recipient is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Condition: Non-Federal entities funded under the reimbursement method must maintain documentation to support that reimbursement was requested prior to the date of the reimbursement request. There were no documented review controls indicating a secondary review of expenditures prior to draw down. Context: For four cash drawdowns, there was no documentation over review of the drawdown support prior to requesting the funds. Cause: There was a lack of review of the drawdowns. Effect: Drawdown requests were not reviewed prior to submission Questioned Costs: None. Repeat Finding: No. Recommendation: All drawdown support should be reviewed prior to requesting the funds. Contact: Vincent Rivers, Executive Director. Corrective Actions Taken or Planned: We have implemented a policy for a program manager to review grant drawdown support prior to requesting funds.
Audit Period: Year End June 30, 2024 The Road Home Corporation d/b/a Louisiana Land Trust (LLT) respectively submits the following corrective action plan for the year ended June 30, 2024. Condition: Louisiana Land Trust (LLT) does not have adequate controls in place to ensure that LLT credit card tr...
Audit Period: Year End June 30, 2024 The Road Home Corporation d/b/a Louisiana Land Trust (LLT) respectively submits the following corrective action plan for the year ended June 30, 2024. Condition: Louisiana Land Trust (LLT) does not have adequate controls in place to ensure that LLT credit card transactions and bank accounts are properly monitored and comply with its own policies and federal program regulations, increasing the risk of theft and fraud. Actions to be taken – 1. Management concurs and has taken action to make certain that all credit card transactions/ statements as well as all bank accounts are monitored on a regular basis to ensure that each account reconciles properly. 2. Management has changed its internal procedures and reassigned responsibilities to staff to help ensure proper checks and balance take place on a regular basis. 3. Management has worked with our new outside CPA firm to integrate all accounts into our bookkeeping system to allow for automatic transaction reconciliations. If there are any questions regarding the actions taken, please feel free to reach out and let me know.
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (Superintendent) compares the meal counts in the claim to the SDS daily meal co...
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (Superintendent) compares the meal counts in the claim to the SDS daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimbursement rates. The reviewer will then sign and date a reconciliation sheet before submission.
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (superintendent) compares the meal counts in the claim to the Skyward daily mea...
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (superintendent) compares the meal counts in the claim to the Skyward daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimursement rates. The reviewer will then sign and date a reconciliation sheet before submission.
Finding Number: 2025-039 Finding: The Health Care Authority did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid and Children’s Health Insurance Program. Program: 93.767 – Children’s Health Insurance Program 93.767 – COVID-19...
Finding Number: 2025-039 Finding: The Health Care Authority did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid and Children’s Health Insurance Program. Program: 93.767 – Children’s Health Insurance Program 93.767 – COVID-19 Children’s Health Insurance Program 93.775 – State Medicaid Fraud Control Units 93.777 – State Survey and Certification of Health Care Providers and Suppliers 93.778 – Grants to States for Medicaid 93.778 – COVID-19 Grants to States for Medicaid Compliance Requirement: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $641 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. Fingerprint based criminal background checks The Authority concurs that a fingerprint-based criminal background check process for high-risk providers was not implemented during the audit period. In coordination with the Centers for Medicare & Medicaid Services (CMS) and the Washington State Patrol, the Authority has developed the required process and is in the final stages of implementation. The program is expected to be launched by March 31, 2026, and will apply to all providers designated as high-risk. Updated license information in ProviderOne When a professional license on a provider record expires, ProviderOne automatically end-dates taxonomies associated with the provider. However, when a provider is enrolled with multiple agencies and only one associated license has expired, the system does not currently end-date the related taxonomies. Currently, 37 of 113,940 servicing-only providers are affected while none of the approximately 9,000 billing providers are impacted. The Authority submitted a system change request in March 2026 to ensure applicable taxonomies are automatically end-dated in these scenarios. In the interim, the Authority developed a weekly report and implemented a process to identify providers with applicable taxonomies that need manually end-dated until the system enhancement is deployed. ProviderOne did not deactivate providers timely ProviderOne is designed to automatically inactivate a provider’s domain when revalidation is not completed timely. Due to an operational issue, a limited number of providers were not deactivated as required. Currently, 50 of approximately 9,000 billing providers are impacted. The Authority submitted a system change request in March 2026 to remediate this issue and prevent recurrence. In the interim, the Authority will conduct weekly monitoring and manually inactivate affected provider domains until the system correction is implemented. Ownership disclosures The Authority does not concur with the determination that it is not in compliance with federal requirements governing ownership disclosures. The Authority’s process requires providers to review and attest to ownership disclosure information maintained by the Authority as part of the revalidation process. The Authority believes this process meets the requirements of 42 CFR 455.104 and appropriately balances regulatory compliance with administrative efficiency. The Authority submitted its procedures to CMS on February 23, 2026, and requested clarification and guidance to ensure continued alignment with federal expectations. Providers not revalidated or deactivated by the five-year deadline The Authority’s revalidation backlog totaled 792 providers in July 2024. Through focused operational improvements and targeted resource deployment, the backlog was substantially reduced to three providers as of June 30, 2025. The Authority remains committed to continuous process improvement to sustain timely revalidations and prevent future backlog growth. As of March 2026, the Authority began working on a daily report of providers nearing the revalidation deadline so they can be prioritized and revalidated timely. Prior Findings: The conditions noted in this finding were previously reported in findings 2024-075, 2023-074, 2022-055, 2021-047, 2020-046, 2019-048, 2018-042, 2017-033, and 2016-035. Completion Date: Estimated March 2026 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager (360) 725-9586 Kari.Summerour@hca.wa.gov
Finding Number: 2025-029 Finding: The Department of Commerce did not have adequate internal controls over and did not comply with the Cash Management Improvement Act requirements for the Low-Income Home and Energy Assistance Program. Program: 93.568 – Low-Income Home Energy Assistance Program Compli...
Finding Number: 2025-029 Finding: The Department of Commerce did not have adequate internal controls over and did not comply with the Cash Management Improvement Act requirements for the Low-Income Home and Energy Assistance Program. Program: 93.568 – Low-Income Home Energy Assistance Program Compliance Requirement: Cash Management Questioned Costs: $0 Status: Corrective action in progress Corrective Action: The Department is in the process of implementing a procedure to comply with the requirements of the Cash Management Improvement Act. In addition, the Department will seek approval from the Department of Health and Human Services for any draws necessary outside of the draw schedule included in the Act. Prior Findings: None Completion Date: Estimated May 2026 Agency Contact: Gena Allen, CFE Internal Control Officer (360) 480-5149 Gena.Allen@Commerce.wa.gov
Finding Number: 2025-006 Finding: The Department of Health did not have adequate internal controls over cash management for the Epidemiology and Laboratory Capacity for Infectious Diseases, the Immunization Cooperative Agreements and the WIC Special Supplemental Nutrition Program for Women, Infants,...
Finding Number: 2025-006 Finding: The Department of Health did not have adequate internal controls over cash management for the Epidemiology and Laboratory Capacity for Infectious Diseases, the Immunization Cooperative Agreements and the WIC Special Supplemental Nutrition Program for Women, Infants, and Children programs. Program: 10.557 – WIC Special Supplemental Nutrition Program for Women, Infants, and Children 93.268 – Immunization Cooperative Agreements 93.268 – COVID-19 Immunization Cooperative Agreements 93.323 – Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 – COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Compliance Requirement: Cash Management Questioned Costs: $160,206 Status: Corrective action in progress Corrective Action: The Department is taking steps to strengthen internal controls over cash management and related system processes. During the audit period, the Department identified issues within the Grants Management System but were unable to implement system enhancements prior to the end of the audit period. The Department will continue to address these system issues to ensure compliance with federal requirements. Additionally, the Department will: • Review and strengthen controls over the accuracy and maintenance of accounting data used in cash draw calculations. • Improve review and monitoring procedures to ensure amounts used to support federal cash draws are accurate, complete, and supported by appropriate documentation. • Evaluate existing roles and responsibilities to ensure appropriate oversight, review, and segregation of duties related to cash management activities. The Department is reviewing the questioned costs identified by the auditors and will take appropriate action in accordance with federal requirements, which may include adjustments or repayment, as necessary. Prior Findings: The conditions noted in this finding were previously reported in findings 2024-036 and 2024-033. Completion Date: Estimated December 2026 Agency Contact: Jeff Arbuckle External Audit Manager (360) 701-0798 Jeff.Arbuckle@doh.wa.gov
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: In order to rectify the finding related to the reporting of the meal claims, Brown County CUSD ...
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: In order to rectify the finding related to the reporting of the meal claims, Brown County CUSD #1 will provide an independent review of the Accuclaim records and the meal claim with a signature indicating approval. The person best suited to provide an approval signature is the superintendent of the district. Management Response: The superintendent agrees with the finding and will perform and document the review as stated in the corrective action plan.
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