Corrective Action Plans

Finding 559996 (2024-001)

Significant Deficiency 2024

DE

Questioned Costs Student Financial Aid Internal Control / Segregation of Duties

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-001: Disbursements: Pell Grant Condition Found: The University utilizes a standard term calendar and therefore should calculate federal student aid under Formula 1 (Volume 7, Chapter 1). Under Formula 1, institutions generally calcula...

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-001: Disbursements: Pell Grant Condition Found: The University utilizes a standard term calendar and therefore should calculate federal student aid under Formula 1 (Volume 7, Chapter 1). Under Formula 1, institutions generally calculate a student’s Scheduled Award and splits such award evenly between the fall and spring semesters. The University offers a winter intersession, but did not combine the winter intersession with the fall or spring semester as prescribed by the Federal Student Aid Handbook when calculating federal student aid awards under Formula 1. Instead, the University used Formula 3 to calculate Pell Grant awards and treated the winter intersession as a separate term and awarded Pell Grants to students for the Winter 2024 intersession. In 2024, the University identified that such approach did not align with applicable Title IV regulations and Department guidance. By using Formula 3 to calculate Pell Grant awards, the University exceeded the students’ standard Scheduled Award. The total amount of over-awarded Pell Grants for the 2023-2024 academic period was $698,000. Recommendation: The auditors recommend the University enhance our internal control over compliance with the federal regulations related to disbursement of Pell Grant awards. The University should enhance how we receive, and process external information to ensure the University is properly awarding federal student aid in accordance with Title IV regulations and Department guidance. Additionally, a control should be designed and implemented for the review of such information. University of Delaware Corrective Action Plan: The University agrees with the finding. The University identified this issue as a result of an extensive review of processes, procedures and internal controls within Student Financial Services with the assistance of both external consultants and outside counsel. Through the University’s research, it was determined that this issue began in 2018 with the reintroduction of Year-Round Pell. The over-awarded amount resulted from the misinterpretation of the regulations and associated guidance and use of the incorrect formula. The University self-identified the issue with the Department of Education and is working towards resolution. The questioned costs of $698,000 related to fiscal year 2024 were refunded to the government through COD system as of September 30, 2024. The University is working with the Department of Education to open prior periods to finalize the repayment of an additional $1.9 million which is expected to be completed by June 30, 2025. The University has implemented internal controls which include the use of the Peoplesoft delivered tools to ensure that Pell is awarded using Formula 1 in accordance with Title IV regulations and Department guidance. The information related to winter intersession aid has been updated to specifically address winter Pell and ensure that it meets required regulations for attaching an intersession to a standard term when using Formula 1 for calculating Pell grant eligibility. Additionally, the University has implemented a weekly reconciliation and over-award reports to monitor for compliance. Completion Date: Return of $698,000 Questioned Costs: September 30, 2024 Implementation of Weekly Reconciliations: November 1, 2024 Return of Additional $1,900,000: Anticipated June 30, 2025 Contact Person: Amanda Steele-Middleton, Assistant Vice President for Enrollment Management

View Audit 355907 Questioned Costs: $1

Finding 559899 (2024-002)

Material Weakness 2024

Struthers City School District

OH

Eligibility School Nutrition Programs Matching / Level of Effort / Earmarking

Beginning in fiscal year 2025, the District has implemented the Community Eligibility Provision (CEP) at all three of its school buildings. The CEP program is in place for four years and it will not be necessary for the District to verify income for free and reduced school lunches during that time p...

Beginning in fiscal year 2025, the District has implemented the Community Eligibility Provision (CEP) at all three of its school buildings. The CEP program is in place for four years and it will not be necessary for the District to verify income for free and reduced school lunches during that time period. If in the future the District no longer participates in CEP, control procedures will be implemented to ensure that all students selected for income verification are being correctly categorized and reported to ODEW. This will include the Cafeteria Manager reviewing the free and reduced lunch applications and forwarding any without necessary documentation to the Superintendent and Treasurer for additional verification for eligibility.

View Audit 355825

Finding 559895 (2024-001)

Material Weakness 2024

Ridgedale Local School District

OH

Eligibility School Nutrition Programs Matching / Level of Effort / Earmarking

All electronic free and reduced meal applications are completed in the PaySchools system. Since PaySchools does not have a SOC1 for Ohio eligibility, all applications will be sent to a pending folder requiring the Food Service Director to review and approve the determination before providing it to t...

All electronic free and reduced meal applications are completed in the PaySchools system. Since PaySchools does not have a SOC1 for Ohio eligibility, all applications will be sent to a pending folder requiring the Food Service Director to review and approve the determination before providing it to the parents/guardians. They began this process reaching out to PaySchools 3/5/2025 and making the change to the account. Because this process started mid-year, the School District will review all of the approved applications prior to 3/31/2025 to avoid a comment in the future.

View Audit 355820

Finding 559739 (2024-001)

Material Weakness 2024

Care Alliance Health Center

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2024 The findings from the October 31, 2024 ...

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2024 The findings from the October 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2024.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients’ needs and complies with all federal guidelines. Care for you. Care for me. Care for all. Our mission is to provide high-quality, comprehensive medical and dental care, patient advocacy and related services to people who need them most, regardless of their ability to pay. info@carealliance.org • www.carealliance.org Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will oversee the training. 3. The Revenue Cycle Manager will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results.

View Audit 355653

Finding 559259 (2024-002)

Significant Deficiency 2024

Kansas Hospital Association

KS

Subrecipient Monitoring Eligibility Significant Deficiency

Identification: 93.889 United States Department of Health and Human Services, COVID-19 National Bioterrorism Hospital Preparedness Program, Significant Deficiency; Eligibility Requirement. Corrective Action Plan: The Association will implement controls related to future awards so that federal fundin...

Identification: 93.889 United States Department of Health and Human Services, COVID-19 National Bioterrorism Hospital Preparedness Program, Significant Deficiency; Eligibility Requirement. Corrective Action Plan: The Association will implement controls related to future awards so that federal funding is only provided to eligible recipients once a signed subaward agreement is on file. Anticipated completion date: The Association anticipates completion in 2025.

View Audit 355477

Finding 559256 (2024-001)

Significant Deficiency 2024

Winter Grove, Inc.

CT

Eligibility HUD Housing Programs

CP-1011 CORRECTIVE ACTION PLAN Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2024 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 Signature:_____...

CP-1011 CORRECTIVE ACTION PLAN Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2024 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 Signature:___________________________________ The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2024-001 a. Comments on the Finding and Each Recommendation The Project did not perform a review of the Enterprise Income Verification (“EIV”) system within 90 days of the tenant moving into the project. And we agree with this finding. b. Action(s) Taken or Planned on the Finding There have been multiple users (Property Managers) assigned to the Enterprise Income Verification System (EIV) to prevent a repeat of this occurrence going forward.

View Audit 355472

Finding 559244 (2024-001)

Material Weakness 2024

Field Local School District

OH

Eligibility School Nutrition Programs Matching / Level of Effort / Earmarking

The District has already been in contact with PaySchools. PaySchools will now put all application information in "Pending Status" and the District will be responsible for review and verification. The District did go back and verify that all applications that were approved by PaySchools did in fact m...

The District has already been in contact with PaySchools. PaySchools will now put all application information in "Pending Status" and the District will be responsible for review and verification. The District did go back and verify that all applications that were approved by PaySchools did in fact meet the threshold levels for all benefits that were approved and denied.

View Audit 355436

Finding 559167 (2024-001)

None 2024

Galapagos Rockford Charter School Nfp, Inc.

IL

Eligibility Reporting

Corrective Action Plan June 30, 2024 Galapagos Rockford Charter School NFP, Inc. respectfully submits the following corrective action plan for the year ended June 20, 2024. Name and address of public accounting firm: Grieco & Adelman LLC 2340 S River Road, Suite 311 Des Plaines, IL 60018 Audi...

Corrective Action Plan June 30, 2024 Galapagos Rockford Charter School NFP, Inc. respectfully submits the following corrective action plan for the year ended June 20, 2024. Name and address of public accounting firm: Grieco & Adelman LLC 2340 S River Road, Suite 311 Des Plaines, IL 60018 Audit Period: June 30, 2024 The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below: Finding No.2023-001: Noncompliance with Federal Filing Requirements Action Taken: Timely filing will be made for the fiscal year ended June 30, 2024 Sincerely yours, 􀀁f-Luu Michael Lane ChiefExecutive Officer

View Audit 355407

Finding 559051 (2024-004)

Significant Deficiency 2024

Knox College

IL

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

Identifying Number: 2024-004 Finding: Common Origination and Disbursement Reporting The College incorrectly reported the COA to COD for 3 students. Out of the 34 students tested, we noted 3 students (8.8%) whose COA was incorrectly reported to COD. The incorrect reporting did not have an effect on ...

Identifying Number: 2024-004 Finding: Common Origination and Disbursement Reporting The College incorrectly reported the COA to COD for 3 students. Out of the 34 students tested, we noted 3 students (8.8%) whose COA was incorrectly reported to COD. The incorrect reporting did not have an effect on the total award given to students (reporting only). The College did not have formally documented controls related to the processes of enrollment reporting and reporting, which is required under Uniform Grant Guidance. Corrective Actions Taken or Planned: The College has moved Financial Aid packaging for all students from CX to PowerFAIDS. This transition has removed the manual processes that caused this error. Person Responsible: Leigh Brinson, lbrinson@knox.edu Anticipated completion date: September 2024

View Audit 355305

Finding 559033 (2024-001)

Significant Deficiency 2024

Santa Monica Christian Towers, Inc. Hud Project No. 122sh088

CA

Eligibility HUD Housing Programs Significant Deficiency

Management agrees with the finding. The Managing Agent has, at its own expense, contracted with US Inspection Group to complete a full inspection of every unit before April 15, 2025. The Managing Agent has prepared a new internal tasking schedule for enhance tracking of unit inspections by the ma...

Management agrees with the finding. The Managing Agent has, at its own expense, contracted with US Inspection Group to complete a full inspection of every unit before April 15, 2025. The Managing Agent has prepared a new internal tasking schedule for enhance tracking of unit inspections by the maintenance, management and executive teams. The Managing Agent will reinforce the critical importance of annual unit inspection during its annual Maintenance Conference and its annual Management Conference.

View Audit 355300

Finding 559026 (2024-004)

Significant Deficiency 2024

Manhattan Christian College

KS

Student Financial Aid Internal Control / Segregation of Duties Eligibility

The College will make the necessary correction to the student's award. Review procedures will be conducted for student awards and disbursements to ensure accuracy for the next fiscal year.

View Audit 355294

Finding 559014 (2024-001)

Significant Deficiency 2024

Community Action Agency of St. Louis County, Inc.

MO

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related ...

CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related documentation is contemporaneously completed and appropriately approved to maintain a strong internal control environment. The current intake and eligibility verification procedures was revised to include explicit language requiring staff signatures and approval of eligibility documentation on the date of service. These updated procedures will reflect both in-office and drive-through (if resumed) operations. All relevant staff members will receive updated training on intake documentation requirements, including the importance of contemporaneous staff review and approval. Training materials will be revised to emphasize compliance with federal requirements related to eligibility documentation. While data entry into MIS may still occur post-service, staff will be required to document and date eligibility approvals on the intake fonns at the time of service. Intake forms will now include a section for immediate staff verification with date stamps to reflect real-time approval. Name of Responsible Person: Linda Huntspon, Chief Executive Officer Anticipated Completion Date: Implemented in January 31, 2025

View Audit 355262

Finding 559003 (2024-001)

Significant Deficiency 2024

Indiana Health Centers, Inc.

IN

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

SIGNIFICANT DEFICIENCIES WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 2024.001 Recommendation We recommend that management provide training for those responsible for verifying eligibility to ensure that documentation and inter...

SIGNIFICANT DEFICIENCIES WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 2024.001 Recommendation We recommend that management provide training for those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken The agency Coordinator will have a training session with each clerk in the agency on the importance of documentation and completion of assessing WIC eligibility. This re-training will include step-by-step instructions. Clerks will be instructed to add notes when needed to explain a client's eligibility, (ex. immigrants and eligibility). Demonstration will be required by each clerk to their supervisor. The re-education will be completed by the end of June 2025 and reported on a log with attendees. Ongoing monitoring will be performed by agency supervisors. They will audit five charts twice a month for each clerk/certifier. In the event, there are deficiencies identified, the supervisor will re-train the clerk/certifier at that time. 1. A folder for each clerk will be kept in a locked cabinet by the agency supervisor. It will contain a log that will consist of the clerk's name, household audited and an analysis of the eligibility that was completed at the certification. 2. Ongoing corrections if needed will be addressed by the agency supervisor or coordinator. Retraining may be requested by clerical staff at any time. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335 or email to tnagel@ihcinc.org.

View Audit 355246

Finding 558995 (2024-002)

Significant Deficiency 2024

Almost Home, Inc.

CO

Eligibility Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

After FY2024, Almost Home ceased using Temporary Assistance for Needy Families (TANF) to cover the cost of Severe Weather Activation Vouchers (SWAP) for TANF-eligible families. From this point forward, TANF will only be used for clients meeting all TANF eligibility requirements.

View Audit 355240

Finding 558971 (2024-006)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Student Financial Aid Special Tests & Provisions Eligibility

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system ...

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system (Banner from Ellucian). All students who have withdrawn are being updated through National Student Clearinghouse and from there to NSLDS.

View Audit 355176

Finding 558862 (2024-065)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

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

Finding: The Community Colleges of Spokane did not have adequate controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: The College District will...

Finding: The Community Colleges of Spokane did not have adequate controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: The College District will enhance our monthly financial reporting to include a unique identifier for monthly expenditures. Additionally, a report of expenditures procured by credit card will be attached to the regular financial report. The College District acknowledges the importance of clear documentation and tracking of the required training and meeting attendance by all Board of Trustees members and Policy Council members. Beginning in March 2025, the College District started providing additional methods and opportunities for new members to receive fiscal and governance training. To strengthen controls over program governance requirements and to demonstrate the commitment to continuous improvement of existing processes, the College District will further document training completion and the distribution of monthly financial information to all members. Completion Date: Estimated June 2025 Agency Contact: Linda McDermott Chief Financial Officer 501 N Riverpoint Blvd, PO Box 6000 Spokane, WA 99217-6000 (509) 434-5275 Linda.McDermott@ccs.spokane.edu

View Audit 355165

Finding 558861 (2024-064)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

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

Finding: Skagit Valley College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: The College has rev...

Finding: Skagit Valley College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: The College has reviewed and strengthened current internal controls to ensure the Board receives the required financial and credit card statements monthly and that all new Board members receive training within the required 180 days. Financial reporting procedures The Head Start Program Director prepares monthly reporting to be available for inclusion in the monthly board packet, or as requested. In January 2025, the Procedures of Policy Council and Board Reporting were updated to ensure that required monthly reporting is provided to each governing body, regardless of whether there is a scheduled meeting for that month. This procedure became effective for the February 2025 Board of Trustees meeting. All financial reporting that was not previously provided to the Board of Trustees for the period covering July 1, 2023, through December 31, 2024, was transmitted on February 24, 2025. Board member training In January 2025, the Head Start Director provided the Board of Trustees an updated document on the program’s selection criteria and enrollment process. Additionally, the Head Start Board of Trustees Handbook, which has incorporated other training materials, was provided to each board member. The Head Start Director will conduct an annual review of the handbook content and update as appropriate to ensure training materials remain current. Completion Date: March 2025 Agency Contact: Mike Cogan VP of Administrative Services and CFO 2405 East College Way Mount Vernon, WA 98273-5899 (360) 899-2945 mike.cogan@skagit.edu

View Audit 355165

Finding 558860 (2024-063)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility

Finding: Edmonds College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: In response to the audit finding, ...

Finding: Edmonds College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: In response to the audit finding, the College will explore options for a Governing Body that complies with governance requirements for the Head Start program. By May 2025, the College will consult with its Assistant Attorney General to discuss the composition of a new Governing Body and will take the necessary steps to fully comply with federal regulations. By July 2025, the College will: • Establish a Governing Body that is compliant with requirements outlined in the Head Start Act to perform the required monthly review of financial and credit card statements, major financial expenditures, and any funding applications. • Ensure the Policy Council receives and approves the required financial and credit card statements each month. • Provide training to the new Governing Body and active members of the Policy Council within the required 180 days. Completion Date: Estimated July 2025 Agency Contact: Ginger Williams Head Start Executive Director 20816 44th Ave. W. Lynnwood, WA 98036-7744 (425) 550-3840 ginger.williams@edmonds.edu

View Audit 355165

Finding 558689 (2024-075)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

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. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 93.775 93.777 93.777 COVID...

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. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $3,844,961 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority does not concur with the auditor’s assertion that two providers did not have a valid Core Provider Agreement on file. The Authority also does not concur that two new providers were enrolled without completion of a full enrollment screening. Corrective action has been in process to address revalidation issues from prior audits. As of January 1, 2024, the Authority implemented a system change moving the revalidation date to 90 days before the end of the five-year period. The Authority is revising existing procedures to strengthen internal controls over provider enrollment. Additional procedure implementation is also in progress to ensure high risk providers receive fingerprint-based background checks. Regarding the nursing facility revalidations, the Authority operates cooperatively under a written agreement with the Department of Social and Health Services (Department) who carry out the nursing facility licensing and revalidations. The Department stated: Effective May 2024, the Department updated the nursing facility revalidation process to require the Facilities Contract Specialist review the nursing facility revalidation monitoring spreadsheet monthly and that revalidation paperwork will be sent one year before the due date to ensure revalidation is done ahead of the 5-year period. In addition, the Department will consult with the Authority to determine if it is feasible to automate the revalidation notices. By December 31, 2025, Department contracts staff will verify that the Medicaid Provider Disclosure Statement forms are in the Management Operation Document Imaging System for all nursing facilities and that each form has been completed within the 5-year period. The conditions noted in this finding were previously reported in findings 2023-074, 2022-055, 2021-047, 2020-046, 2019-048, 2018-042, 2017-033, and 2016-035. Completion Date: Estimated December 2025 Agency Contact: William Sogge External Audit Compliance Specialist PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov

View Audit 355165 Questioned Costs: $1

Finding 558663 (2024-069)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Eligibility

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure a child is eligible and group care facility employees and adults residing in prospective caregivers’ households had cleared background checks before having unsupervised access to children. Q...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure a child is eligible and group care facility employees and adults residing in prospective caregivers’ households had cleared background checks before having unsupervised access to children. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. For the specific exceptions identified in the finding, the Department has taken the following actions: Individuals: • Updated the source of funds in the FamLink application for the child identified in the audit exception to ensure future payments would be made with state funds. • Researched all payments made on behalf of the child and returned the federal portion to the grantor. • Updated the peer review process to ensure that a sample of cases are reviewed quarterly and all documentation is properly retained. Background Checks: • In January 2024, the Department increased its use of National Crime Information Center (NCIC) background checks to ensure all individuals required to complete fingerprint-based checks are compliant prior to a child’s placement. • The Department continues to use the Plan, Do, Check, Act (continuous quality improvement process) to communicate changes and provide additional training to staff as needed to ensure compliance with the background check requirement. The conditions noted in this finding were previously reported in findings 2023-068 and 2022-050. Completion Date: January 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165 Questioned Costs: $1

Finding 558661 (2024-067)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Sta...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. As stated in the finding’s Cause of Condition, the Department did not fully implement the prior year’s corrective action plan during the audit period and did not have the reporting capabilities to track rate setting reviews for the entire audit period. To strengthen internal controls and documentation, and as part of the implementation of the new rate assessment process, the Department took the following corrective actions: • Published a new report in FamLink to assist rate assessors in identifying: o Six-month reviews that have not been performed timely. o Cases with upcoming rate assessments and due dates for reviews. • Implemented monthly tracking by supervisors to assist with internal controls and compliance. The Department continues to use the Plan, Do, Check, Act (continuous quality improvement process) to improve the accuracy of the new reports and provide additional training to staff as needed to ensure compliance with the requirement of performing six-month reviews of the reimbursement rates. The conditions noted in this finding were previously reported in finding 2023-067. Completion Date: June 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165

Finding 558642 (2024-048)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with federal requirements to ensure subrecipients of the Refugee and Entrant Assistance programs received required single audits, and that it followed up on findings and issued mana...

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with federal requirements to ensure subrecipients of the Refugee and Entrant Assistance programs received required single audits, and that it followed up on findings and issued management decisions. Questioned Costs: Assistance Listing # 93.566 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially concurs with the auditor’s findings. The Department’s Office of Refugee and Immigrant Assistance (ORIA) has taken corrective actions to strengthen controls over subrecipient monitoring. During the fiscal year, the program verified each subrecipient’s total federal financial assistance through online tax forms and determined if a single audit report is required. For subrecipients that met the single audit threshold, ORIA either received the single audit report from the subrecipient or accessed the Federal Audit Clearinghouse database to obtain a copy. However, the Department did not issue management decisions when applicable. By May 2025, the Department will work with the Division of Finance and Financial Resources (DFFR) to review all subrecipients’ single audit reports for state fiscal year 2024. Any audit findings related to activities funded by ORIA awards will be identified for necessary actions. By June 2025, as applicable, the Department will issue management decision letters for the findings outlining the determination of the effectiveness of the subrecipient’s proposed corrective action to address findings. By July 2025, the Department will: • Work with DFFR to implement effective internal controls and develop written procedures to ensure subrecipients receive required single audits; and to issue written management decisions as needed. • Monitor subrecipients’ corrective actions for findings received to ensure they are completed. The conditions noted in this finding were previously reported in finding 2023-053. Completion Date: Estimated July 2025 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 355165

Finding 558637 (2024-043)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over eligibility requirements for child care services paid with the Child Care and Development Fund and Temporary Assistance for Needy Families funds. Questioned Costs: Assistance Listing # 93.55...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over eligibility requirements for child care services paid with the Child Care and Development Fund and Temporary Assistance for Needy Families funds. Questioned Costs: Assistance Listing # 93.558 93.575 93.575 COVID-19 93.596 Amount $0 Status: Corrective action complete Corrective Action: In response to prior audit findings, the Department developed a corrective action plan to address the internal control deficiencies. This finding was issued due to the corrective action plan not being fully implemented during the audit period. To address the prior years’ eligibility audit findings, the Department has taken the following actions: • As of April 2024, conducted a root cause analysis of internal audit findings, particularly for cases with errors due to household composition and approved activities, and updated the desk aid with corrective actions identified. • As of May 2024: o Improved and published the desk aid outlining simplified eligibility determination process that includes procedures for those families who do not have an approved activity. o Developed updated household composition training for all staff as part of core childcare training. The Department will continue to partner with the Administration for Children and Families and follow our program integrity plan. The conditions noted in this finding were previously reported in findings 2023-059, 2022-036, 2021-035, 2020-039, 2019-032, 2018-030, 2017-026, 2016-023, 2015-026, 2014-026, 2013-017, and 12-30. Completion Date: May 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 558615 (2024-035)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Health did not have adequate internal controls to ensure providers maintained immunization records, control, accountability and safeguarding of vaccines for the Immunization Cooperative Agreements Program. Questioned Costs: Assistance Listing # 93.268 93.268 COVID-...

Finding: The Department of Health did not have adequate internal controls to ensure providers maintained immunization records, control, accountability and safeguarding of vaccines for the Immunization Cooperative Agreements Program. Questioned Costs: Assistance Listing # 93.268 93.268 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department has already taken steps to evaluate current processes to ensure providers maintain immunization records, control, accountability and safeguarding of vaccines for the Immunization Program. As of July 2024, the program implemented a more automated process in the RedCap system to identify the vaccine doses administered outside the age range (DOAR) activities. This process enables adequate reviews and follow up with providers to be performed for the DOAR reports. As of November 2024, the site visit coordinator began the process of closely monitoring site visits due in one month and reaching out to the regional representatives to determine the status of scheduling site visits in order to minimize delays. The Department will continue to conduct monthly site visits and outreach and follow internal policies and procedures to meet DOAR reporting requirements. Completion Date: November 2024 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov

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Finding 558475 (2024-016)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

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

Finding: The Housing Finance Commission did not have adequate internal controls over earmarking requirements for the Homeowner Assistance Fund program. Questioned Costs: Assistance Listing # 21.026 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Commission h...

Finding: The Housing Finance Commission did not have adequate internal controls over earmarking requirements for the Homeowner Assistance Fund program. Questioned Costs: Assistance Listing # 21.026 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Commission has taken the following corrective actions to strengthen controls over earmarking requirements for the Homeowner Assistance Fund (HAF) program: • Developed a system to track and monitor expenditures in relation to overall program expenditures to ensure earmarking requirements are within allowable parameters. • Selected an increased percentage of approved, denied, and withdrawn HAF applications that have previously been reviewed by the contractor, as part of the Quality Control process, for a secondary review by program staff. • Reviewed a selection of HAF applications independent of the Quality Control process performed by the contractor. • Reviewed a selection of approved HAF applications prior to disbursing funds to confirm eligibility determinations are proper. The conditions noted in this finding were previously reported in finding 2023-023. Completion Date: October 2024 Agency Contact: Lucas Loranger Senior Finance Director 1000 Second Ave, Suite 2700 Seattle, WA 98104-3601 (206) 464-7139 Lucas.Loranger@wshfc.org

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Corrective Action Plans

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