Corrective Action Plans

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 559002 (2024-003)

None 2024

Town of Colchester, Ct

CT

Reporting Internal Control / Segregation of Duties

The Town has reviewed the reporting procedures and how to maintain accurate expenditures, in accordance with U.S. Treasury guidelines. This corrective action has been sustained for the March 2025 filing, and will be adhered to for any subsequent reporting by the Director of Finance and the First S...

The Town has reviewed the reporting procedures and how to maintain accurate expenditures, in accordance with U.S. Treasury guidelines. This corrective action has been sustained for the March 2025 filing, and will be adhered to for any subsequent reporting by the Director of Finance and the First Selectman.

View Audit 355244

Finding 558996 (2024-002)

Material Weakness 2024

Audubon Community School District

IA

Internal Control / Segregation of Duties Reporting

We will continue to review our control procedures to obtain the maximum internal controls possible under the circumstances.

View Audit 355241

Finding 558986 (2024-006)

Material Weakness 2024

Dakota Rural Water District

ND

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318 § 200.326

Environmental Protection Agency, passed through State of North Dakota Department of Environmental Quality Federal Financial Assistance Listing 66.468 Capitalization Grants for Drinking Water Procurement, Suspension, Debarment Material Weakness Finding Summary: The District did not have a written p...

Environmental Protection Agency, passed through State of North Dakota Department of Environmental Quality Federal Financial Assistance Listing 66.468 Capitalization Grants for Drinking Water Procurement, Suspension, Debarment Material Weakness Finding Summary: The District did not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Jordyne Lee, General Manager Corrective Action Plan: The District will review the applicable 2 CFR 200 sections and implement procedures necessary to ensure compliance with all of these requirements. Anticipated Completion Date: December 31, 2025.

View Audit 355234

Finding 558985 (2024-006)

Material Weakness 2024

Shelter and Assistance in Family Emergencies, Inc.

MS

Questioned Costs Internal Control / Segregation of Duties Cash Management

Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual wil...

Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual will be responsible for preparing reimbursement requests and subsequently submitting them; 4) provided extensive training to staff involved in the grant reimbursement procedures; 5) implemented a centralized grant tracking sheet to monitor billed amounts by category and date that is verified by two staff members; 6) implemented a quarterly internal audit review by a Board of Directors member with any findings reported to the Board of Directors for oversight.

View Audit 355230 Questioned Costs: $1

Finding 558982 (2024-002)

None 2024

Calvin Court, Atlanta, Inc.

GA

Cash Management HUD Housing Programs Internal Control / Segregation of Duties

Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes tha...

Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.

View Audit 355218

Finding 558981 (2024-001)

None 2024

Calvin Court, Atlanta, Inc.

GA

Internal Control / Segregation of Duties

Recommendations: We recommend the Organization implement and follow a checklist of procedures for moveout occurrences to ensure security deposits due upon move-out are returned in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are...

Recommendations: We recommend the Organization implement and follow a checklist of procedures for moveout occurrences to ensure security deposits due upon move-out are returned in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.

View Audit 355218

Finding 558976 (2024-001)

Significant Deficiency 2024

Community Health Center Dba Alluvion Health, Inc.

MT

Internal Control / Segregation of Duties Special Tests & Provisions Significant Deficiency

Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The inform...

Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The information provided for the training will be translated to a process document and provided to all registration staff and billers. Colleagues will be expected to use this document as reference guide to improve program adherence. 4. Registration colleagues will participate in a peer review process where each colleague reviews 5 accounts monthly. They will audit demographics and insurance, as well as slide fee program adherence. Feedback will be provided to the colleagues responsible for errors to make corrections. 5. A leadership team member supervising patient registration colleagues will continue to audit 50 patient accounts each month. The accounts selected will have at least one billable medical, behavioral health, SUD, or dental encounter in the audit month. The audit criteria will include identifying the colleague responsible for inputting income information and application of discounts. Errors identified through the audit process will be sent to the colleage responsible for correction. Supervision and coaching will be provided to colleagues while fixing their errors to improve future performance. Responsible Party(s): Melissa Darko, Revenue Cycle Director and Lisa DeMallie, Associate Vice President of Patient Experience Estimated Completion Date: Applications were streamlined in March 2025; training was provided in April 2025 and will be ongoing; a process document will be provided to staff in May 2025; peer reviews were started in February 2025; and auditing has been ongoing and will continue.

View Audit 355210

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 558965 (2024-004)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Internal Control / Segregation of Duties Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Monitor compliance through regular internal reviews and sample audits of personnel records.

View Audit 355176

Finding 558956 (2024-003)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Cash Management Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. C...

Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. Conduct training to clarify and reinforce individual roles and responsibilities. Introduce periodic internal reviews to verify compliance with segregation protocols.

View Audit 355176

Finding 558949 (2024-002)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management § 200.305

Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the G...

Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the Grant monthly reconciliation to Federal and State Funds Administration Office, Compliance officer reviews the reconciliation and Director of Federal Funds Administration determine needed funds to be requested. A new Enterprise Resource Planning (ERP) software it’s under implementation and will address this issue as part of the implementation process.

View Audit 355176

Finding 558941 (2024-002)

Significant Deficiency 2024

Fisk University

TN

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financ...

Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financial reporting and audit preparation processes. Items that can be compiled prior to year-end will be identified and the compilation of those items will begin. Areas that presented challenges during the FY 24 audit will be given special attention in advance. Lastly, audit assignments will be delegated to improve response efficiency. A detailed closing schedule has been developed. Staff duties and responsibilities have been reassigned and repurposed to improve processing timelines and audit preparation. The audit timeline will be monitored more closely to ensure timely responses to audit requests that support the timely completion and issuance of the audit to meet Uniform Guidance timeline requirements.

View Audit 355168

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 558859 (2024-062)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties

Finding: Edmonds College did not have adequate internal controls over and did not comply with protection of federal interest requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response ...

Finding: Edmonds College did not have adequate internal controls over and did not comply with protection of federal interest requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response to the audit finding, Edmonds College has completed the following: • Established a written protocol with the Department of Enterprise Services (DES) to ensure the Head Start Program Performance Standards 1303.46 is met in recording and posting federal interest. • Established internal controls to ensure college management monitor future work with DES to properly complete the Office of Head Start Lease Rider attachment in the lease agreements where federal funds are used to renovate leased property. Completion Date: February 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 558858 (2024-061)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties

Finding: Edmonds College did not have adequate controls over reporting for its Head Start Program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response to the audit finding, the College established a documented procedu...

Finding: Edmonds College did not have adequate controls over reporting for its Head Start Program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response to the audit finding, the College established a documented procedure for the compilation and submission of the SF-425 reports to ensure compliance with federal requirements. This procedure includes: • Defining roles and responsibilities of staff. • Performing a secondary review of all reports before submission. • Retaining source data used in creating the reports. Completion Date: April 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 558785 (2024-081)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Material Weakness Reporting

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 concurs with the finding and continues to develop and implement its statewide surveillance and utilization control program by: • Updating its Surveillance Utilization Review Subsystem policies and procedures. • Updating and documenting its statewide monitoring program. • Documenting its internal control program to ensure it complies with all utilization control requirements. The conditions noted in this finding were previously reported in findings 2023-082, 2022-061, 2021-050, 2020-047, 2020-048, 2019-052, 2019-053, and 2018-047. In fiscal year 2024, the State Auditor’s Office determined the Authority resolved findings 2020-047, 2020-048, 2019-052, 2019-053, and 2018-047. Completion Date: Estimated June 2026 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 42724 Olympia, WA 98504-2691 (360) 725-9586 Kari.Summerour@hca.wa.gov

View Audit 355165

Finding 558783 (2024-079)

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 Department of Social and Health Services, Aging and Long-Term Support Administration did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 9...

Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially concurs with the finding. The Department was not able to meet the Nursing Home Recertification Survey requirements due to a backlog from prior years, not because of lack of internal controls. It was through applied internal controls that we identified concerns and were able to allocate resources to meet the most serious concerns. The Department made efforts in fiscal year 2023 and 2024 to address the backlog of complaints and recertification surveys, but resources had to be prioritized for new complaints. There is only one team that manages surveys, complaints, and revisits for the entire state. To optimize the use of resources, the Field Manager meets with the Administrative Assistant on a quarterly basis to review the 365-day average report and determine if survey schedules need to be modified to meet federal requirements To continue to address this audit issue, regional administrators have met with their Nursing Home teams to review survey scheduling for the year to ensure teams will be able to meet targeted survey completion dates and the required survey and recertification timeframes. By January 2026, the Department expects to meet compliance with the 15.9-month recertification survey timeline and the 12.9-month statewide average. The conditions noted in this finding were previously reported in findings 2023-079 and 2020-054. Completion Date: Estimated January 2026 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 355165

Finding 558781 (2024-077)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it referred all credible allegations of provider fraud to the state’s Medicaid Fraud Control Unit. Questioned Costs: Assistance Listing # 93.775 9...

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it referred all credible allegations of provider fraud to the state’s Medicaid Fraud Control Unit. 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 and its contractor, Consumer Direct Care Network Washington (CDWA), identify potential and suspected provider fraud and refer fraud allegations with a potential loss of $1,000 or more to the Medicaid Fraud Control Unit (MFCU). Fraud referrals under $1,000 are all reviewed and tracked to enable repeat referrals to be identified and compiled to show a pattern of possible fraudulent behaviors. For cases under $1,000, CDWA completes provider education and training on billing standards, which will be documented and used to support any future referrals. The 15 cases identified in the audit finding that were not referred to MFCU were each under $1,000 of potential loss. Provider education was completed by CDWA, and the funds were returned to Medicaid. As of February 2025, the Department met with CDWA to discuss a revised process that will ensure compliance with MFCU requirements. In addition, the Medicaid Provider Fraud Referral form DSHS 12-210 was modified to include CDWA as an entity. By May 2025, the Department and CDWA will: • Revise and finalize existing procedures related to the referrals of all credible allegations of fraud to MFCU regardless of the amount of potential loss. • Request approval for the creation of a ticketing system for CDWA to submit provider fraud referrals directly into SharePoint. This will streamline the process, reduce workload, and help ensure compliance with MFCU requirements. Completion Date: Estimated May 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 558780 (2024-076)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Health did not have adequate internal controls over and did not comply with requirements to ensure timely review of hospital complaints. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action complete ...

Finding: The Department of Health did not have adequate internal controls over and did not comply with requirements to ensure timely review of hospital complaints. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action complete Corrective Action: The Department has a process in place to screen complaints for possible imminent danger. The Department has assessed and strengthened internal controls within the licensing and regulatory systems that are necessary to demonstrate compliance. The systems will properly reflect the accurate date of initial screening for imminent danger within two working days of receiving a complaint, as required by the Centers for Medicare and Medicaid Services State Operations Manual, and subsequent 21-day basic assessment and review timeline per internal policies. Additionally, the Department is performing quarterly audits to confirm and document that timely screening of complaints is taking place as required. The conditions noted in this finding were previously reported in finding 2023-076. Completion Date: August 2024 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov

View Audit 355165

Finding 558728 (2024-030)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it communicated federal award identification elements to subrecipients of the Aging Cluster Programs. Questioned Costs: Assistance Listing # 93.04...

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it communicated federal award identification elements to subrecipients of the Aging Cluster Programs. Questioned Costs: Assistance Listing # 93.044 93.044 COVID-19 93.045 93.045 COVID-19 93.053 Amount $0 Status: Corrective action complete Corrective Action: The Department concurs with the finding. This is a repeat finding of the same issues reported in the previous year due to the corrective action plan not being completed until July 2024. As of July 2024, the Department implemented the following procedures: • Included Initial Notices of Award (NOA), with the required 14 federal identification elements, in the initial subaward as Exhibit D in the contracts. • Added language to the subaward document informing Area Agencies on Aging (AAAs) that NOAs are posted online. • Fiscal staff to notify all AAA fiscal staff via email when new NOAs are posted. • Contracts staff to attach Exhibit D to the initial subaward before signing the contract. The conditions noted in this finding were previously reported in finding 2023-040. Completion Date: July 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 355165

Finding 558688 (2024-074)

Material Weakness 2024

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 managed care financial audit requirements. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action com...

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with managed care financial audit requirements. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action complete Corrective Action: Audited financial reports: The Authority amended the managed care contract to require Managed Care Organizations to submit financial statements prepared in accordance with Generally Accepted Accounting Principles and Generally Accepted Auditing Standards. The amended contract requirement went into effect January 1, 2025. Periodic audits: The Authority implemented internal controls during state fiscal year 2024 to ensure periodic audits are completed within the required timeline. The conditions noted in this finding were previously reported in findings 2023-073, 2022-054, and 2021-048. Completion Date: June 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 42724 Olympia, WA 98504-2691 (360) 725-9586 Kari.Summerour@hca.wa.gov

View Audit 355165

Finding 558664 (2024-070)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Reporting Subrecipient Monitoring Material Weakness

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with reporting requirements for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Act...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with reporting requirements 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 follow the U.S. Department of Health and Human Services’ (HHS) published instructions. To address the auditor’s specific recommendations, the Department has: • Reviewed and updated all electronic versions of the quarterly crosswalks to align with HHS instructions. • Submitted a correction to the April 2025 quarterly report. The conditions noted in this finding were previously reported in findings 2023-069 and 2022-051. Completion Date: April 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165

Corrective Action Plans

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