Corrective Action Plans

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CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended December 31, 2023. Finding 2023-002 Responsible Party Name: Fred Gibbs Position: President – Management Agent Telephone Number: 913-709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Purchase or Refinancing of Existing Multifamily Rental Housing (Section 207/223(F)) Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action We will deposit the shortfall of $544 into the reserve for replacement account, as well as the shortfalls for 2019, 2020, 2021 and 2022, as soon as possible and ensure the process is being followed to deposit and reconcile the reserve for replacement account on a monthly basis. Anticipated Completion Date June 30, 2024
View Audit 307115 Questioned Costs: $1
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended December 31, 2023. Finding 2023-001 Responsible Party Name: Fred Gibbs Position: President – Management Agent Telephone Number: 913-709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Purchase or Refinancing of Existing Multifamily Rental Housing (Section 207/223(F)) Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action We will follow our policies and procedures to ensure that accounting records are kept accurate and complete, and a responsible official will review and sign off on the monthly financial statements. Anticipated Completion Date June 30, 2024
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Wahkiakum School District No. 200 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code o...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Wahkiakum School District No. 200 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate controls for ensuring compliance with federal requirements for allowable costs and cost principles Name, address, and telephone of District contact person: Sue Ellyson, Business Manager P.O. Box 398 Cathlamet, WA 98612 (360) 795-3971 Corrective action the auditee plans to take in response to the finding: The District will be more prompt in requesting refunds. Anticipated date to complete the corrective action: The refund was requested 3/1/24 and received 3/15/24.
View Audit 307112 Questioned Costs: $1
Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Andrea Cooper 2689 Hoover Ave SE Port Orchard, WA 98366 360-874-7015 Corrective...
Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Andrea Cooper 2689 Hoover Ave SE Port Orchard, WA 98366 360-874-7015 Corrective action the auditee plans to take in response to the finding: The District was compliant with federal wage rates and will ensure that all public works projects funded with federal funds have appropriate contract language included in order to comply with all federal wage rate requirements. Anticipated date to complete the corrective action: Immediately.
The Chief Executive Officer (CEO) and LANWT accounting department will review and train on 45 CFR 1631 regarding the subject of Purchasing and Property Management. LANWT will review its policies and protocols to require prior purchase approval and exigent circumstances approval. Deadlines shall be c...
The Chief Executive Officer (CEO) and LANWT accounting department will review and train on 45 CFR 1631 regarding the subject of Purchasing and Property Management. LANWT will review its policies and protocols to require prior purchase approval and exigent circumstances approval. Deadlines shall be calendared by the CEO and the accounting department whenever there is an exigent circumstance and approval will need to be requested within the 30-day notice period. The CEO will remain in periodic contact with LSC if any extenuating circumstances exist. The accounting manual will be updated with this protocol. Date of Completion: June 1, 2024 Person Responsible to Ensure Completion: Maria Thomas-Jones, CEO
Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Accounting staff should reconcile the Replacement Reserve account on a periodic (monthly or quarterly) basis to ensure the monthly transfers are being made. Management should also make the deposit to fully fund the replaceme...
Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Accounting staff should reconcile the Replacement Reserve account on a periodic (monthly or quarterly) basis to ensure the monthly transfers are being made. Management should also make the deposit to fully fund the replacement reserve as soon as possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in agreement with the finding and has since corrected the issue. Name(s) of the contact person(s) responsible for corrective action: Chuck Armstrong, Director Independent & Affordable Living Planned completion date for corrective action plan: September 30, 2023
View Audit 307011 Questioned Costs: $1
Name of auditee: Adirondack Community Action Programs, Inc. TIN: 14-1490418 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: June 1, 2022 - May 31, 2023 CAP prepared by: Alan Jones ajones@acapinc.org Finding 2023-001 Adirondack Community Action Programs Inc. (ACAP) is committed to...
Name of auditee: Adirondack Community Action Programs, Inc. TIN: 14-1490418 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: June 1, 2022 - May 31, 2023 CAP prepared by: Alan Jones ajones@acapinc.org Finding 2023-001 Adirondack Community Action Programs Inc. (ACAP) is committed to addressing the finding highlighted in the Independent Auditor's Report on Compliance regarding late filing of the Data Collection Form. We recognize the importance of timely reporting for organizational compliance. We were fortunate to receive significant additional unexpected financial resources in the year in question to assist with COVID recovery and support for our work in Child Care. These additional resources were welcomed, but created a temporary significant increase in the workload for our business office. We pride ourselves on our internal controls and comprehensive financial procedures and expect this delay to be isolated to the year in question. As in the past, ACAP will: • Ensure adequate staffing levels given the increases we have been experiencing in annual revenue. • Continue to review our internal processes related to financial reporting and filing deadlines. Identify any bottlenecks or inefficiencies contributing to the delays. • Continue to foster effective communication channels among team members responsible for financial reporting. Continue to ensure everyone understands their roles and responsibilities in meeting filing deadlines. • As always encourage training and development opportunities for staff. • Consider engaging external consultants or advisors to provide guidance around best practices. • Continue to foster a culture of continuous improvement within the organization. Encourage feedback from staff members on ways to streamline processes and identify opportunities for improvement. By implementing these corrective actions, ACAP is confident that we can address this late filing finding and strengthen our financial reporting practices moving forward. We are committed to ensuring timely and accurate reporting to uphold the trust and confidence of our stakeholders.
Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Angela Bowen 516 Silverbrook Rd, Randall, WA 98377 360-497-3791 Corrective action t...
Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Angela Bowen 516 Silverbrook Rd, Randall, WA 98377 360-497-3791 Corrective action the auditee plans to take in response to the finding: The White Pass School District will immediately implement the following controls to assure that the District has adequate internal controls in place for any future expenditures for Capital Projects where federal funds will be used. 1-The District will review the Federal Procurement and contractor requirements prior to submitting applications to use federal funds for Capital Projects. 2- The District will have a meeting with the appropriate staff involved with the project to insure that compliance with the Federal Program Procurement including compliance with the federal wage rate requirements are met. 3- As part of the verification process to ensure adequate internal controls the District will identify who the person will be who will secure and monitor weekly certified payroll from the contractors to stay in compliance with the federal wage rate requirements at the beginning of each project. Anticipated date to complete the corrective action: Effective immediately 5/13/2024
Finding #2023-003 - Material Adjustments (Prior year finding #2022-003) Condition: Johnson Block and Company, Inc. proposed numerous adjusting journal entries. We deem these entries to be significant in relation to the financial statements. Since the District did not make these adjustments in its a...
Finding #2023-003 - Material Adjustments (Prior year finding #2022-003) Condition: Johnson Block and Company, Inc. proposed numerous adjusting journal entries. We deem these entries to be significant in relation to the financial statements. Since the District did not make these adjustments in its accounting system prior to the audit, a material weakness exists in the District’s internal controls. Effect: This means that the proper recording and reporting of financial information may not occur within a timely manner. Cause: Financial information was not recorded in a timely manner and material adjustments were needed in order to correct various transactions. Criteria: Material adjusting journal entries not prepared by the District before the audit are considered an internal control weakness. Recommendation: Policies and procedures should be implemented to ensure account balances are properly recorded in a timely manner. Response: The District will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the auditor. Contact Person: John Costello Anticipated Completion: June 30, 2024
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Riverside School District No. 416 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of ...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Riverside School District No. 416 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Lisa Bjorklund, Business Manager Riverside School District No. 416 34515 N Newport Hwy Chattaroy, WA 99003-9734 Corrective action the auditee plans to take in response to the finding: In the future the district will comply with the federal prevailing wage requirements as part of our internal control process. Riverside will provide a weekly statement for all federal prevailing wage contracts; contracts will have all applicable Davis Bacon language in the contract prior to the start of any work. Riverside will comply with all applicable under Title 2 CFR Part 200, Title 29 CFR Section 3.3, and Title 29 CFR Section 5.5. Anticipated date to complete the corrective action: The corrective action will be in place as of May 20, 2024.
Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Paul Wieneke, Southside School District 161 SE Collier Rd Shelton, WA 98584 (360) 426-8437 Corrective ac...
Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Paul Wieneke, Southside School District 161 SE Collier Rd Shelton, WA 98584 (360) 426-8437 Corrective action the auditee plans to take in response to the finding: When engaging in any future state or federally funded capital project, the district will implement further internal controls to ensure compliance with all prevailing wage requirements. The district will keep a record of communication with the contractor, noting the date and time that weekly prevailing wages are monitored and are confirmed as accurate. The district will provide additional training to ensure staff overseeing compliance with federal programs are aware of all applicable requirements. Anticipated date to complete the corrective action: May 6, 2024
Finding 2023-006: Material Weakness in Internal Control over Compliance - Special Tests and Provisions ...
Finding 2023-006: Material Weakness in Internal Control over Compliance - Special Tests and Provisions Corrective Action Plan: I. The DLR RA Management Analyst will prepare and submit all ETA Reports (Preparer). a. The Management Analyst will initially enter all data into the report and ensure its initial accuracy. b. The Management Analyst will also be responsible for addressing any warning message(s) or error message(s) that are generated by the reporting system. c. Once the data has been entered and all warning and error messages have been addressed, the Management Analyst will notify the DLR RA Senior Internal Auditor that the ETA Report is complete and ready for their review. 2. The DLR RA Senior Internal Auditor will Review and Sign Off on all ETA reports (Reviewer) a. The Senior Auditor will review the completed report to ensure its accuracy. b. If an issue is found during the review, it will be researched and corrected. c. Once the Senior Internal Auditor has verified all data elements within the report are correct, they will email the Management Analyst signing off on the data presented and give approval for the Management Analyst to submit the final report. 3. The Management Analyst submits the final report. 4. Once submitted, the Management Analyst will print the submitted copy of the final report to PDF. 5. Once in PDF form, the Management Analyst will add the following notes: a. Prepared By: [Name] b. Date and Time c. Reviewed By: [Name] d. Date and Time 6. With the "Prepared/Reviewed Note" added, it is now considered the "Finalized Report." 7. The Management Analyst will save an electronic copy of the Finalized Report along with copies of any supporting documentation and any email communications between the "Preparer" and the "Reviewer" to the QA records to be retained according to DLR Record Retention policies. 8. All RA Staff can access all finalized reports through the RA MS SharePoint site. Contact Person: Pauline Heier, Director, Reemployment Assistance Anticipated Completion Date: No anticipated completion date was listed in the separately issued audit report.
Finding 2023-005: Material Weakness in Internal Control over Compliance - Reporting ...
Finding 2023-005: Material Weakness in Internal Control over Compliance - Reporting Corrective Action Plan: I. The DLR RA Management Analyst will prepare and submit all ETA Reports (Preparer). a. The Management Analyst will initially enter all data into the report and ensure its initial accuracy. b. The Management Analyst will also be responsible for addressing any warning message(s) or error message(s) that are generated by the reporting system. c. Once the data has been entered and all warning and error messages have been addressed, the Management Analyst will notify the DLR RA Senior Internal Auditor that the ETA Report is complete and ready for their review. 2. The DLR RA Senior Internal Auditor will Review and Sign Off on all ETA reports (Reviewer) a. The Senior Auditor will review the completed report to ensure its accuracy. b. If an issue is found during the review, it will be researched and corrected. c. Once the Senior Internal Auditor has verified all data elements within the report are correct, they will email the Management Analyst signing off on the data presented and give approval for the Management Analyst to submit the final report. 3. The Management Analyst submits the final report. 4. Once submitted, the Management Analyst will print the submitted copy of the final report to PDF. 5. Once in PDF form, the Management Analyst will add the following notes: a. Prepared By: [Name] b. Date and Time c. Reviewed By: [Name] d. Date and Time 6. With the "Prepared/Reviewed Note" added, it is now considered the "Finalized Report." 7. The Management Analyst will save an electronic copy of the Finalized Report along with copies of any supporting documentation and any email communications between the "Preparer" and the "Reviewer" to the QA records to be retained according to DLR Record Retention policies. 8. All RA Staff can access all finalized reports through the RA MS SharePoint site. Contact Person: Pauline Heier, Director, Reemployment Assistance Anticipated Completion Date: No anticipated completion date was listed in the separately issued audit report.
Finding No. 2023-004: Inadequate Controls over the Payment of Claims ...
Finding No. 2023-004: Inadequate Controls over the Payment of Claims Corrective Action Plan: The claim initiation duties have been separated from the claim approval responsibilities. When a claim is initiated in FACIS, that request can only be approved by someone with permissions to review and approve claims on the case. Reviewing and approving authorizations on the FACIS system can only be issued to an individual on CPS staff who does not have claim entry responsibilities. Payment is generated only after approval is completed. During the period audited, the FACIS system did not save information about which staff member had approved the claim. This left no record to verify the name and date for claim approvals. Contact Person: Jason Simmons, Chief Financial Officer, Department of Social Services Anticipated Completion Date: In state fiscal year 2024, FACIS was updated to fully document this information for later retrieval and review, essentially the implementation of this corrective action plan prior to the completion of DLA's audit; therefore, this finding has been corrected.
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....
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 Amount $0 Status: Corrective action in progress Corrective Action: The Authority does not concur with the auditor’s conclusion that it needs to update the state plan to include all methods and procedures used to safeguard against unnecessary utilization of care and services. The Authority has received written guidance from the Centers for Medicare & Medicaid Services (CMS) that it does not need to individually list the methods and procedures but rather complete the template document in the state plan and select from a list of applicable methods. CMS approved this portion of the state plan effective July 1, 2023. The Authority has adequate internal controls to ensure compliance with utilization control requirements and partially concurs with the auditor’s recommendation related to implementing and monitoring a statewide surveillance and utilization control program. The Authority recently updated the Fraud and Detection System (FADS) and is in the process of updating policies and procedures related to FADS operation and the statewide surveillance and utilization control program. The FADS system triggers alerts and judgmental sampling is used by staff to assess risk and determine follow-up procedures. The system is in its early implementation phase and the Authority is still in the process of establishing written criteria. The conditions noted in this finding were previously reported in findings 2022-061, 2021-050, 2020-047, 2020-048, 2019-052, 2019-053, and 2018-047. Completion Date: Estimated December 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov
Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it periodically audited cost report data for rate setting, hospital billings, and other financial and statistical records for inpatient hospital services. Questioned Cos...
Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it periodically audited cost report data for rate setting, hospital billings, and other financial and statistical records for inpatient hospital services. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Health Care Authority partially concurs with the audit finding. The Authority does not audit inpatient hospital cost reports because it is not a federal requirement. The Authority has updated the Washington Administrative Code and its State Plan to align with federal regulations. The Authority partially concurs with the auditor’s assertion that it does not audit hospital and financial and statistical records. The Authority contracts for audits of Disproportionate Share Hospitals which includes roughly half of the hospitals in Washington. These audits include other financial and statistical records and meet this requirement. The auditor was provided information regarding these audits. The Authority will develop a desk audit process to review the financial statements of Washington hospitals, as necessary, and will create policies and procedures related to this process. The Authority does not concur with the auditor’s conclusion that it does not audit hospital billings or have methodology, policies, or procedures related to these audits. The Authority conducts utilization review and payment integrity audits of inpatient hospitals on an ongoing basis, which includes verification of billed charges. This information is well-documented and was provided to the auditor during the audit. The Authority will continue to formally document its internal controls over this compliance area. The conditions noted in this finding were previously reported in findings 2022-060, 2021-051, and 2020-049. Completion Date: Estimated October 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov
Finding: The Department of Social and Health Services’ Aging and Long-Term Support Administration did not have adequate internal controls over and did not comply with requirements to ensure timely investigation of complaints of client abuse and neglect at Medicaid residential facilities. Questio...
Finding: The Department of Social and Health Services’ Aging and Long-Term Support Administration did not have adequate internal controls over and did not comply with requirements to ensure timely investigation of complaints of client abuse and neglect at Medicaid residential facilities. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees that it did not meet the Immediate Jeopardy and Non-Immediate Jeopardy complaint timelines due to the backlog created by the public health emergency and a 20 percent staff vacancy rate. The Department does not agree that it was due to lack of internal controls. Over the past two years, the Department had 30 new staff who were not certified to complete investigations independently; there were only three available trainers who spent the majority of their time in 2022 and early 2023 addressing training needs. Once staff completed the training and applied for certification, testing sites were limited resulting in staff having difficulty finding available testing slots. In late 2022, this process transitioned from in-person to virtual which provided greater opportunity for timelier certification. As of March 31, 2023, all staff have the required certification, and the training backlog has been resolved. As of February 2024, Immediate Jeopardy (2 days) complaints were completed on time. The Department implemented a procedure to review the status of intakes at the regional level monthly to ensure timelines continue to remain compliant for Immediate Jeopardy complaints. By June 2024, the Department will ensure Non-Immediate Jeopardy intakes are completed in a timely manner. Once the Department is in compliance with Non-Immediate Jeopardy complaints, the monthly review procedures will also be implemented. The conditions noted in this finding were previously reported in findings 2022-057 and 2021-054. Completion Date: Estimated June 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 ...
Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees that it did not meet the Nursing Home Recertification Survey requirements, due to the backlog created by the public health emergency and a 20 percent staff vacancy rate. The Department does not agree that it was due to lack of internal controls. It was through applied internal controls that we identified the need to hire a contractor to assist with the recertification backlog to meet compliance requirements. As of March 2024, the Department met the 15.9-month recertification timeline. The 12.9-month statewide average is based on the overall average of months for all nursing home surveys, which included some of those surveys that were in a significant backlog due to the pandemic. Statistically, even when the state is meeting the 15.9-month timeframe for each home and lowering the number of months between surveys, it is expected that the bell curve average will take time to shift toward 12.9 months. The Department believes this will be achieved by January 2026. The conditions noted in this finding were previously reported in finding 2020-054. Completion Date: Estimated January 2026 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid intermediate care facilities. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 C...
Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid intermediate care facilities. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID 93.778 93.778 COVID Amount $0 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees that it did not meet the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) Survey requirements, due to the backlog created by the public health emergency and a 20 percent staff vacancy rate. The Department does not agree that it was due to lack of internal controls. It was through applied internal controls that we identified concerns and were able to allocate resources to meet the most serious concerns. As of March 2024, the Department: • Met the 15.9-month recertification timeline. • Created a statement of deficiency and plan of correction tracking tool in Smartsheet for each team in Residential Care Services to track deadlines. This system generates automatic email alerts to key staff on approaching deadlines and when recertification deadlines have arrived. The 12.9-month statewide average is based on the overall average of months for all ICF-IID surveys, which included some of those surveys that were in a significant backlog due to the pandemic. Statistically, even when the state is meeting the 15.9-month timeframe for each home and lowering the number of months between surveys, it is expected that the bell curve average will take time to shift toward 12.9 months. The Department believes this will be achieved by January 2026. The conditions noted in this finding were previously reported in findings 2020-053, 2019-061, 2018-052, 2017-042, 2016-037, 2015-045, 2014-046. Completion Date: Estimated January 2026 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
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 in progre...
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 in progress Corrective Action: The Department has a process to screen complaints for possible imminent danger and will evaluate current procedures to identify necessary changes to ensure initial screening dates are properly reflected for subsequent assessment and review. The Department will also strengthen internal controls to ensure our licensing and regulatory systems are sufficient in managing the process of handling all facilities complaints to capture the screening for imminent danger within two working days. Once that process is complete, the Department will perform quarterly audits to confirm and document that timely screening of complaints is taking place as required. The Department will also identify strategies to improve staffing challenges and stability. Completion Date: Estimated December 2024 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $0 Status: C...
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $0 Status: Corrective action in progress Corrective Action: The Department is strongly committed to ensuring the health, safety, and well-being of all children in care. The Department concurs with the finding and has taken the following actions: • In the fall of 2022, the Department began recruiting new staff to address staff turnover issues and providing training on child care licensing rules and regulations. • In November 2022, added new positions to assist supervisors with onboarding and training new staff and focused training on monitoring visits, caseload management, and health and safety requirements. • Implemented a data driven, phased in approach, to return staff to in-person field work after the COVID-19 pandemic: o In July 2022, implemented return to in-person field work by reducing pandemic level requirements and authorizing staff to visit providers on-site to assist with meeting health and safety requirements. o In February 2023, developed and implemented a field practice onboarding process to streamline training for newly hired staff on practices to support the annual monitoring of all licensed child care providers. o In the spring of 2023, prioritized monitoring visits to return to compliance with Child Care and Development Fund program health and safety requirements. • Conducted a root cause analysis to determine other underlying causes for missed monitoring visits and untimely follow-ups, and how to address them. • For license-exempt family, friend, and neighbor (FFN) providers, the Department: o Received approval from the Office of Child Care for a hybrid monitoring approach (in-person and virtual visits). o Dedicated staff resources to update the WA Compass system to include all health and safety requirements for FFNs and address data format issues. Completion Date: Agency Contact: The Department will continue to strengthen internal controls as follows: For licensed providers: • Create in-training licensing positions to assist with staff recruitment efforts. • Continue to track and monitor health and safety requirements with available tools until all WA Compass system development is completed. • Examine ways to secure resources to add additional full-time staff to support caseload needs. For FFN providers: • Continue to track and monitor FFN health and safety requirements with available tools until all WA Compass system development is completed. The conditions noted in this finding were previously reported in findings 2022-045, 2021-039, 2020-042, 2019-039, 2018-035, 2017-025, 2016-022 and 2015-024. Estimated July 2025 Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with client eligibility requirements for child care services paid with the Child Care and Development Fund and Temporary Assistance for Needy Families funds. Questioned Costs: ...
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with client 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 Status: Corrective action in progress Corrective Action: The Child Care and Development Fund (CCDF) program was previously managed by the Department of Social and Health Services and the Department of Early Learning. Since the program transitioned in 2019, the Department has been making efforts to strengthen internal controls over payments to child care providers and other CCDF grant requirements. The Department will continue to maintain internal controls using our program integrity procedures, utilizing a combination of centralized and local case reviews to identify error trends, identify root causes, and develop solutions to the root causes. To address the fiscal year 2023 eligibility audit findings, the Department will: • Conduct root cause analysis of internal audit findings, particularly for cases with errors due to household composition and approved activities, and develop appropriate corrective actions as needed. • Develop and deliver updated household composition training for all staff. • Improve and publish the desk aid outlining simplified eligibility determination process that includes procedures for those families who do not have an approved activity. The conditions noted in this finding were previously reported in findings 2022-036, 2021-035, 2020-039, 2019-032, 2018-030, 2017-026, 2016-023, 2015-026, 2014-026, 2013-017 and 2012-30. Completion Date: Estimated July 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov
Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it filed reports required by the Federal Funding Accountability and Transparency Act. Questioned Costs: Assistance Listing # 93.044 93.044 COVID-19 93...
Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it filed reports required by the Federal Funding Accountability and Transparency Act. Questioned Costs: Assistance Listing # 93.044 93.044 COVID-19 93.045 93.045 COVID-19 93.053 Amount $0 Status: Corrective action in progress Corrective Action: The Department concurs with the finding. As of January 2024, the Department: • Created a subawards and amendments tracking spreadsheet with the required fields and contract information for reports required by the Federal Funding Accountability and Transparency Act (FFATA). • Assigned two fiscal staff to ensure FFATA reporting activities are submitted in the Federal Funding Accountability and Transparency Subaward Reporting System (FSRS). As of February 2024, the Department: • Ensured federal fiscal year 2024 funded contracts that were executed in December 2023 for the Office of Aging were entered in FSRS. • Added procedures for the Office Chief or designee to review the subawards and amendments tracking spreadsheet monthly for FFATA reporting to ensure federal deadlines are met consistently. By July 2024, the Department will collaborate with the Administration of Community Living to develop a plan to address the FFATA reporting backlog in state fiscal years 2022 and 2023, and to ensure all FFATA reports are entered in FSRS for all previous years. Completion Date: Estimated 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
Finding: The Department of Social and Health Services did not have adequate internal controls to ensure individuals are eligible to receive benefits for the Money Follows the Person program. Questioned Costs: Assistance Listing # 93.791 Amount $0 Status: Corrective action complete Correc...
Finding: The Department of Social and Health Services did not have adequate internal controls to ensure individuals are eligible to receive benefits for the Money Follows the Person program. Questioned Costs: Assistance Listing # 93.791 Amount $0 Status: Corrective action complete Corrective Action: The Department partially agrees with the finding. The Department agrees that the Financial and Social Services Communication (14-443) forms were not provided to terminate the enrollment of the four exceptions identified in the finding. However, in those exceptions, the Roads to Community Living (RCL) disenrollment communication was made in accordance with the existing Nursing Facility Case Management policy as defined in Chapter 10 of the Long-Term Care (LTC) Manual. In addition, all clients met eligibility criteria for RCL services or were converted to another Home and Community Based program within the 365-day RCL demonstration year limitation. In these cases, the client was converted to a state plan or waiver with the new program start date noted on the 14-443 forms. The 14-443 form is a communication tool used by the Department’s public benefit specialists. For Modified Adjusted Gross Income (MAGI) enrolled Medicaid participants, benefits are managed by the Washington State Health Care Authority and the 14-443 form is not required or used by the Department’s public benefit specialists. This MAGI beneficiary communication detail was not articulated in the RCL chapter of the LTC Manual. As of May 2024, the Department updated Chapter 29 of the LTC Manual to clarify instructions related to when the 14-443 form must be completed for MAGI participants and what needs to be included on the form when it is required. Completion Date: May 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
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 93.775 93.777 93.777 COVID 93...
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 93.775 93.777 93.777 COVID 93.778 93.778 COVID Amount $0 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority does not concur that four providers did not receive a proper license check, nor that the backdated provider was noncompliant with regulations prior to receiving a National Provider Identifier (NPI). When a provider’s license expires, the Authority enters an end date for the provider taxonomy to prevent future payments. The Authority does not pay claims without an NPI and this is compliant with federal requirements. Corrective action has been in process to address revalidation issues. 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 developing additional procedures to strengthen internal controls over provider enrollment. The conditions noted in this finding were previously reported in findings 2022-055, 2021-047, 2020-046, 2019-048, 2018-042, 2017-033, and 2016-035. Completion Date: Estimated December 2024 Agency Contact: William Sogge, CPA, CIA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov
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