Corrective Action Plans

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Student Support and Academic Enrichment – Assistance Listing No. 84.424 Recommendation: We recommend Boston Public Schools review and enhance internal controls and procedures to ensure that they retain copies of correspondence with private schools to ensure completeness and accuracy of the calculati...
Student Support and Academic Enrichment – Assistance Listing No. 84.424 Recommendation: We recommend Boston Public Schools review and enhance internal controls and procedures to ensure that they retain copies of correspondence with private schools to ensure completeness and accuracy of the calculation. Action taken in response to finding: In August 2025, Boston Public Schools developed and implemented a revised policy on equitable services that ensures that all communication is stored in a centralized folder for standard reviews. Name(s) of the contact person(s) responsible for corrective action: Marcela Mahecha, Director of Federal & State Grants, Programs, and Compliance Boston Public Schools Planned completion date for corrective action plan: August 31, 2025
Housing Opportunities for Persons with Aids – Assistance Listing No. 14.241 Recommendation: We recommend the Mayor’s Office of Housing review and enhance internal controls and procedures to ensure that required inspections are performed timely. Action taken in response to finding: The Mayor’s Office...
Housing Opportunities for Persons with Aids – Assistance Listing No. 14.241 Recommendation: We recommend the Mayor’s Office of Housing review and enhance internal controls and procedures to ensure that required inspections are performed timely. Action taken in response to finding: The Mayor’s Office of Housing, as the HOPWA Grantee, identifies deficiencies in timely completions and documentations of HQS inspections performed by the project sponsor. The sponsor has now fully transitioned to using the Yardi system for property management activities, which will enhance inspection tracking and reporting, and has established monthly inspection monitoring reports to identify upcoming or past-due inspections. These corrective actions address the cause of missing yearly inspections and strengthen internal controls for ongoing compliance. The Mayor’s Office of Housing will ensure continued compliance through quarterly reviews of HQS inspection reports (submitted by the sponsor) and complete targeted file monitoring to verify timely completion and documentation, including any deficiency corrections. Name(s) of the contact person(s) responsible for corrective action: Kiarah Perdomenico, Housing Development Officer HOPWA program manager Planned completion date for corrective action plan: April 3, 2026
Economic Development Cluster - Assistance Listing No. 11.307 Recommendation: We recommend the Mayor’s Office of Workforce Development develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to SAM.gov no later than the end of the month follow...
Economic Development Cluster - Assistance Listing No. 11.307 Recommendation: We recommend the Mayor’s Office of Workforce Development develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to SAM.gov no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The City has implemented a more timely FFATA review and submission procedure in FY25/FY26, however due to this award having been transferred from another organization this was not able to be submitted on Sam.gov. The City made multiple attempts to have the award updated in the system but due to this program ending, there was no contact available to remedy this issue. Name(s) of the contact person(s) responsible for corrective action: Colin Musto, Assistant City Auditor Planned completion date for corrective action plan: March 1, 2026
2024-008 Material Weakness and Noncompliance, Reporting (Repeat Finding 2024-008) Audit Finding: The Town improperly included encumbrances in expenditures on three of four quarterly reports due to a lack of understanding of reporting requirements (ARPA). As this was identified at the end of FY25, th...
2024-008 Material Weakness and Noncompliance, Reporting (Repeat Finding 2024-008) Audit Finding: The Town improperly included encumbrances in expenditures on three of four quarterly reports due to a lack of understanding of reporting requirements (ARPA). As this was identified at the end of FY25, the fourth quarter report properly excluded encumbrances and reflected correction of this issue. Corrective Action Taken: As noted above and in this report, this was corrected as soon as we became aware of the issue, for fourth quarter reporting in FY25 and continues going forward. Anticipated Completion Date: In Process as of April 2025. Name and Phone # of Person Responsible for Implementation Joan Lynch, Comptroller, 203-622-2226
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV – Waiting List Recommendation: We recommend the Authority review its Agent’s internal controls over the waiting list process to ensure all documentation is maintained at the time each applicant is selected from the waiting list an...
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV – Waiting List Recommendation: We recommend the Authority review its Agent’s internal controls over the waiting list process to ensure all documentation is maintained at the time each applicant is selected from the waiting list and that applicants are added to the waitlist accurately. We recommend the Authority implements uniform documentation standards and requirements across all local housing agencies (LHAs) and agents of the Authority. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority recognizes the need to strengthen documentation controls at the point of applicant selection. As part of its broader compliance review, the Authority is evaluating improvements to waiting list procedures. This includes reviewing documentation requirements, selection verification protocols, and file completeness standards. Enhancements under consideration include: - Providing training to LHAs on waiting list management, referral processes, extension documentation, and documentation retention requirements - Incorporating a quality control (QC) review of referrals to special purpose voucher programs to ensure documentation, eligibility verification, and notification records are consistently maintained - Strengthening monitoring procedures to validate that required documentation is retained at the time of selection Name of the contact person responsible for corrective action: Yilla Smith, Director, Housing Opportunity Programs and Initiatives Planned completion date for corrective action plan: December 31, 2026
FINDING 2025-013 Finding Subject: Head Start Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Adrian Wilkerson, Chief Financial Officer Chris Akers, Treasurer Artiya Nash, Head Start Director Contact Phone Number and Email A...
FINDING 2025-013 Finding Subject: Head Start Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Adrian Wilkerson, Chief Financial Officer Chris Akers, Treasurer Artiya Nash, Head Start Director Contact Phone Number and Email Address: awilkerson@chsnewtech.com cakers@chsnewtech.com anash@chsnewtech.com 219-838-1819 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The business office will generate a payroll distribution report by fund after each payroll period. This report will list each individual paid from this fund. This report will be provided to the grant director and will be signed and dated and returned to the business office to be filed with the payroll file. Anticipated Completion Date: This will be implemented immediately. 62
FINDING 2025-010 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Assessment System Security Contact Person Responsible for Corrective Action: Adrian Wilkerson, Chief Financial Officer Chris Akers, Treasurer Cynthia Mose-Trevino, Assistant Superintendent...
FINDING 2025-010 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Assessment System Security Contact Person Responsible for Corrective Action: Adrian Wilkerson, Chief Financial Officer Chris Akers, Treasurer Cynthia Mose-Trevino, Assistant Superintendent Corporation Test Coordinator Contact Phone Number and Email Address: awilkerson@chsnewtech.com cakers@chsnewtech.com cynthia.mose-trevino@chsnewtech.com 219-838-1819 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A two layer verification of completion will be implemented by each building level STC ensuring completion of test security training at their site, and the CTC verifying this completion data for all required district personnel. Anticipated Completion Date: This revised process will be fully implemented by the beginning of the 2027 calendar year.
FINDING 2025-009 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Contact Person Responsible for Corrective Action: Regin Johnson, Title 1 Director Rae Lopez, Student Services Director Contact Phone Number and Email Address: rjohnson@chsnewtech.com rlopez@chsnewtech.com 21...
FINDING 2025-009 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Contact Person Responsible for Corrective Action: Regin Johnson, Title 1 Director Rae Lopez, Student Services Director Contact Phone Number and Email Address: rjohnson@chsnewtech.com rlopez@chsnewtech.com 219-838-1819 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The error causing this finding is within part of the annual student registration process. If a parent did not provide the socio-economic status (SES) data necessary to determine Title I eligibility, the student information system defaulted their SES to a former value. To correct this error, the collection of the SES data will be reviewed by the data manager to identify missing information. School registrars will request the parent/guardian provide any missing information. Students that have no current SES data by student count day will be automatically flagged as ineligible for the Title I count. This verified data will be what is submitted to the IDOE Data Exchange. Anticipated Completion Date: This revised process will be implemented for the 2026-2027 school year enrollment registration process. 58 INDIANA STATE BOARD OF ACCOUNTS 60
FINDING 2025-008 Finding Subject: Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Adrian Wilkerson, Chief Financial Officer Chris Akers, Treasurer Regin Johnson, Title I Grant Director C...
FINDING 2025-008 Finding Subject: Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Adrian Wilkerson, Chief Financial Officer Chris Akers, Treasurer Regin Johnson, Title I Grant Director Contact Phone Number and Email Address: awilkerson@chsnewtech.com cakers@chsnewtech.com rjohnson@chsnewtech.com 219-838-1819 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The business office will generate a payroll distribution report by fund after each payroll period. This report will list each individual paid from this fund. This report will be provided to the grant director and will be signed and dated and returned to the business office to be filed with the payroll file. All claims submitted to the business office for payment will need to be signed by the grant director prior to payment. The grant director will provide a detailed invoice, and grant expenditure account information. Anticipated Completion Date: This will be implemented immediately.
Child Care and Development Fund Cluster (93.575, 93.596) COVID-19 Child Care and Development Fund Cluster (93.575, 93.596) State Agency: Department of Human Services Federal Agency: U.S. Department of Health and Human Services Reporting – Federal Financial Accountability and Transparency Act (FFATA)...
Child Care and Development Fund Cluster (93.575, 93.596) COVID-19 Child Care and Development Fund Cluster (93.575, 93.596) State Agency: Department of Human Services Federal Agency: U.S. Department of Health and Human Services Reporting – Federal Financial Accountability and Transparency Act (FFATA) VIEWS OF RESPONSIBLE OFFICIALS AND CORRECTIVE ACTION PLAN The New Jersey Department of Human Services’ Division of Family Development (DHD/DFD) has taken significant steps to ensure the effective management of FFATA (Federal Funding Accountability and Transparency Act) data. DHD/DFD has appointed qualified personnel dedicated to the accurate reporting of FFATA information. All appointed personnel have undergone comprehensive training programs designed to equip them with the knowledge and skills required for accurate entry and maintenance of FFATA data. DHD/DFD and its internal units will work in close coordination to manage, review, and validate FFATA submissions. COMPLETION DATE/ CONTACT PERSON June 30, 2026 Robert Hughes (609) 584-4041 Robert.Hughes@dhs.nj.gov
Temporary Assistance for Needy Families (93.558) State Agency: Department of Human Services Federal Agency: U.S. Department of Health and Human Services Reporting – Federal Financial Accountability and Transparency Act (FFATA) VIEWS OF RESPONSIBLE OFFICIALS AND CORRECTIVE ACTION PLAN The New Jersey ...
Temporary Assistance for Needy Families (93.558) State Agency: Department of Human Services Federal Agency: U.S. Department of Health and Human Services Reporting – Federal Financial Accountability and Transparency Act (FFATA) VIEWS OF RESPONSIBLE OFFICIALS AND CORRECTIVE ACTION PLAN The New Jersey Department of Human Services’ Division of Family Development (DHD/DFD) has taken significant steps to ensure the effective management of FFATA (Federal Funding Accountability and Transparency Act) data. DHD/DFD has appointed qualified personnel dedicated to the accurate reporting of FFATA information. All appointed personnel have undergone comprehensive training programs designed to equip them with the knowledge and skills required for the accurate entry and maintenance of FFATA data. DHD/DFD and its internal units will work in close coordination to manage, review, and validate FFATA submissions. COMPLETION DATE/ CONTACT PERSON June 30, 2026 Robert Hughes (609) 584-4041 Robert.Hughes@dhs.nj.gov
Workforce Innovation and Opportunity Act (WIOA) Cluster (17.258, 17.259, 17.278) State Agency: Department of Labor and Workforce Development Federal Agency: U.S. Department of Labor Reporting – Federal Funding Accountability and Transparency Act (FFATA) VIEWS OF RESPONSIBLE OFFICIALS AND CORRECTIVE ...
Workforce Innovation and Opportunity Act (WIOA) Cluster (17.258, 17.259, 17.278) State Agency: Department of Labor and Workforce Development Federal Agency: U.S. Department of Labor Reporting – Federal Funding Accountability and Transparency Act (FFATA) VIEWS OF RESPONSIBLE OFFICIALS AND CORRECTIVE ACTION PLAN The New Jersey Department of Labor and Workforce Development (DLWD) has transitioned from a manual contract agreement process to a web-based grant administration system using the System for Administering Grants Electronically (SAGE) and IntelliGrants (IGX) applications. The DLWD FFATA Reporting Unit accesses these automated systems and monitors them monthly to identify new Subaward contracts/agreements for timely reporting in the FFATA system. Additionally, the DLWD Fiscal & Accounting Division will complete the full implementation of this transition by developing stronger internal controls and procedures to ensure that all required subawards are reported no later than the end of the month following issuance, in accordance with FFATA reporting requirements. COMPLETION DATE/ CONTACT PERSON July 31, 2026 Ahmanish Robinson (609) 984-4356 Ahmanish.Robinson@dol.nj.gov Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov
Finding Number: 2025-003 Condition: The project description in the grant award specified that activities would be performed within disadvantaged opportunity zones. However, during the period of performance, DWSD incurred $4.1 million in expenditures related to lead service line replacements that wer...
Finding Number: 2025-003 Condition: The project description in the grant award specified that activities would be performed within disadvantaged opportunity zones. However, during the period of performance, DWSD incurred $4.1 million in expenditures related to lead service line replacements that were performed outside of those designated zones. At the time the costs were incurred, DWSD did not have controls in place to ensure that project activities continued to align with the geographic requirements of the award or to promptly notify the granting agency when activities could not be performed as originally planned. Planned Corrective Action: DWSD has since implemented geographical verification controls that incorporate grant standards, aligned checklists and policy updates. Pre-expenditure approval process will be strengthened including training. Contact person responsible for corrective action: Istakur Rahman Anticipated Completion Date: 6/30/2026
Finding Number: 2025-002 Condition: DWSD did not have controls in place to verify that required contract provisions were included in contracts executed under this award or to ensure receipt of weekly certified payroll records from all contractors. Planned Corrective Action: DWSD will improve contrac...
Finding Number: 2025-002 Condition: DWSD did not have controls in place to verify that required contract provisions were included in contracts executed under this award or to ensure receipt of weekly certified payroll records from all contractors. Planned Corrective Action: DWSD will improve contract provisional and certified payroll monitoring controls, as well as provide training on federal contract requirements. These improvements start with incorporating pre-execution compliance checklist and completing compliance reviews. In addition, formal standardized payroll submission process will be required weekly, where applicable. This process will include monitoring contractor payroll tracking logs, review and approvals, and payment controls for missing or inaccurate payroll documentation. Contact person responsible for corrective action: Istakur Rahman Anticipated Completion Date: 6/30/2026
SPECIAL EDUCATION CLUSTER – SUSPENSION AND DEBARMENT U.S. Department of Education Special Education Cluster Assistance Listing Number: 84.027 & 84.173 Passed Through Minnesota Department of Education Pass Through Number: H027A220087 Award Period: July 1, 2024 – June 30, 2025 Recommendation: We recom...
SPECIAL EDUCATION CLUSTER – SUSPENSION AND DEBARMENT U.S. Department of Education Special Education Cluster Assistance Listing Number: 84.027 & 84.173 Passed Through Minnesota Department of Education Pass Through Number: H027A220087 Award Period: July 1, 2024 – June 30, 2025 Recommendation: We recommend the District formalizes their suspension & debarment procedures in a policy and ensure they check suspension & debarment for all vendors prior to entering into a covered transaction. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The District will work on educating all of the personnel involved in the procurement processes to ensure the compliance requirements are fully understood and a proper review of all procurements and procurement methods will be performed. This will be implemented by June 30, 2026 and the School Board will be responsible for monitoring the status. Name of the contact person responsible for corrective action: Tom Sager, Executive Chief of Financial Services Planned completion date for corrective action plan: June 30, 2026
CHILD NUTRITION CLUSTER – SUSPENSION AND DEBARMENT U.S. Department of Agriculture Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.556, 10.559, 10.582 Passed Through Minnesota Department of Education Pass Through Number: 10.CNC Award Period: July 1, 2024 – June 30, 2025 Recommen...
CHILD NUTRITION CLUSTER – SUSPENSION AND DEBARMENT U.S. Department of Agriculture Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.556, 10.559, 10.582 Passed Through Minnesota Department of Education Pass Through Number: 10.CNC Award Period: July 1, 2024 – June 30, 2025 Recommendation: We recommend the District formalizes their suspension & debarment procedures in a policy and ensure they check suspension & debarment for all vendors prior to entering into a covered transaction. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The District will work on educating all of the personnel involved in the procurement processes to ensure the compliance requirements are fully understood and a proper review of all procurements and procurement methods will be performed. This will be implemented by June 30, 2026, and the School Board will be responsible for monitoring the status. Name of the contact person responsible for corrective action: Tom Sager, Executive Chief of Financial Services Planned completion date for corrective action plan: June 30, 2026
The University of Massachusetts acknowledges the enrollment status of certain students was not accurately or timely transmitted to the National Student Loan Data System (NSLDS). The University will implement additional controls and procedures to ensure data is transmitted to NSLDS correctly and time...
The University of Massachusetts acknowledges the enrollment status of certain students was not accurately or timely transmitted to the National Student Loan Data System (NSLDS). The University will implement additional controls and procedures to ensure data is transmitted to NSLDS correctly and timely, including increased reviews of data submitted to NSDLS, and a reconciliation of student status with NSLDS. The corrective action plan will be implemented by May 31, 2026. For further details regarding the corrective action plan, contact the Assistant Vice President and University Controller, Patrick Hitchcock, at phitchcock@umassp.edu
Finding Number: 2025-005 Condition: The College did not include their Community Facilities Loans on the Schedule of Federal Expenditures in prior years. Planned Corrective Action: The College will ensure that updates to compliance requirements are identified and complied with through review of Compl...
Finding Number: 2025-005 Condition: The College did not include their Community Facilities Loans on the Schedule of Federal Expenditures in prior years. Planned Corrective Action: The College will ensure that updates to compliance requirements are identified and complied with through review of Compliance supplements and other resources. The College will continue to reconcile grant funds received to the SEFA to ensure that all appropriate programs are included. Contact person responsible for corrective action: Kayla Flanders Anticipated Completion Date: 6/30/2026
Finding Number: 2025-006 Condition: The College did not notify students receiving loan or TEACH disbursements within 30 days of crediting the students' account. Planned Corrective Action: The College agrees with the finding. The College will review the internal processes and procedures around studen...
Finding Number: 2025-006 Condition: The College did not notify students receiving loan or TEACH disbursements within 30 days of crediting the students' account. Planned Corrective Action: The College agrees with the finding. The College will review the internal processes and procedures around student notification to ensure that all required notifications are completed within the designated timeframe. The CFO and Controller will work with the Financial Aid office to ensure the process is documented and complied with. Contact person responsible for corrective action: Kayla Flanders Anticipated Completion Date: 6/30/2026
We concur with the finding. The Municipality has reclassified all expenditures to the appropriate program fund and project codes corresponding to each individual PW. In addition, the Finance Department has assigned program and accounting staff to ensure the proper recording and classification of exp...
We concur with the finding. The Municipality has reclassified all expenditures to the appropriate program fund and project codes corresponding to each individual PW. In addition, the Finance Department has assigned program and accounting staff to ensure the proper recording and classification of expenditures, thereby maintaining compliance with FEMA and other funding requirements. Implementation date: February 23, 2026 Responsable Person: Mrs. Omayra Báez Caraballo Finance Department Director
We concur with the finding. The Municipality has implemented the following corrective measures: The Municipality provides training to personnel responsible for grant reporting, covering the preparation and timely submission of all CDBG financial reports, including proper documentation and reconcilia...
We concur with the finding. The Municipality has implemented the following corrective measures: The Municipality provides training to personnel responsible for grant reporting, covering the preparation and timely submission of all CDBG financial reports, including proper documentation and reconciliation of program expenditures. The Municipality has assigned a staff member to monitor all grant reporting deadlines and coordinate with the pass-through entity to ensure timely report submissions. Implementation date: July 1, 2026 Responsible Person: Mrs. Omayra Báez Caraballo Finance Department Director
Finding Number: 2025-049 Finding: The Health Care Authority did not have adequate internal controls over and did not comply with Recovery Audit Contractor requirements for the Medicaid program. Program: 93.775 – State Medicaid Fraud Control Units 93.777 – State Survey and Certification of Health Car...
Finding Number: 2025-049 Finding: The Health Care Authority did not have adequate internal controls over and did not comply with Recovery Audit Contractor requirements for the Medicaid program. Program: 93.775 – State Medicaid Fraud Control Units 93.777 – State Survey and Certification of Health Care Providers and Suppliers 93.778 – Grants to States for Medicaid 93.778 – COVID-19 Grants to States for Medicaid Compliance Requirement: Special Tests and Provisions – Medicaid Recovery Audit Contractors (RACs) Questioned Costs: $0 Status: Corrective action complete Corrective Action: The Authority partially concurs with the finding. The Authority concurs it did not have a Recovery Audit Contractor (RAC) contract in place during fiscal year 2025 but does not concur with the auditor’s recommendation. The Authority signed a contract with its vendor on September 30, 2025. The work of the RAC contractor is one of many tools used by the Authority to identify and report fraud, waste, and abuse. The Authority has policies and procedures in place for claim reviews and recoveries, fraud referrals, and compliance with the Centers for Medicare and Medicaid Services reporting requirements. The work of the RAC contractor is intended to supplement the Authority’s Program Integrity work and will be incorporated into its current workflows. Prior Findings: None Completion Date: September 2025 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager (360) 725-9586 Kari.Summerour@hca.wa.gov
Finding Number: 2025-048 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. Program: 93.775 – State Medica...
Finding Number: 2025-048 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. Program: 93.775 – State Medicaid Fraud Control Units 93.777 – State Survey and Certification of Health Care Providers and Suppliers 93.778 – Grants to States for Medicaid 93.778 – COVID-19 Grants to States for Medicaid Compliance Requirement: Special Tests and Provisions – Medicaid Fraud Control Unit Questioned Costs: $0 Status: Corrective action complete Corrective Action: The Department concurs with the finding. The Department completed corrective actions in April 2025 for the prior year’s audit finding by implementing enhanced internal controls to ensure that all fraud referrals, regardless of dollar amount, are submitted to the Medicaid Fraud Control Unit (MFCU). The audit identified 17 credible allegations within the Aging and Long-Term Support Administration and two within the Developmental Disabilities Administration. These credible allegations occurred prior to April 2025, preceding both the process improvements and the completion of the fiscal year 2024 corrective action plan. All 19 credible allegations were under $1,000 and while those may not have been referred to MFCU, the Department’s contractor, Consumer Direct Care Network Washington, did provide provider education and ensured all funds were returned to the Centers for Medicare and Medicaid Services. Prior Findings: The conditions noted in this finding were previously reported in finding 2024-077. Completion Date: April 2025 Agency Contact: Richard Meyer External Audit Compliance Manager Richard.Meyer@dsha.wa.gov
Finding Number: 2025-047 Finding: The Department of Social and Health Services, Home and Community Living Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid intermediate care facilities. Program: 93.775 – State Medicaid Fraud Control...
Finding Number: 2025-047 Finding: The Department of Social and Health Services, Home and Community Living Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid intermediate care facilities. Program: 93.775 – State Medicaid Fraud Control Units 93.777 – State Survey and Certification of Health Care Providers and Suppliers 93.778 – Grants to States for Medicaid 93.778 – COVID-19 Grants to States for Medicaid Compliance Requirement: Special Tests and Provisions – Provider Health and Safety Standards Questioned Costs: $0 Status: Corrective action in progress Corrective Action: The Department partially concurs with the finding. The Department was not able to meet the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) 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 address the most serious concerns. The Department has made efforts since fiscal year 2023 to address the backlog of complaints and recertification surveys, but resources had to be prioritized to handle 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 ICF-IID teams to review survey scheduling for the year to ensure teams will be able to meet targeted survey completion dates and the required recertification timeframes. As of November 2025, the Department met compliance with the 15.9-month recertification survey interval measure based on the 2025 CMS State Performance Measurement Report. By August 2026, the Department expects to meet compliance with the 12.9-month statewide average. Prior Findings: The conditions noted in this finding were previously reported in findings 2024-078, 2023-078, 2020-053, 2019-061, 2018–052, 2017-042, 2016-037, 2015-045, and 2014-046. Completion Date: Estimated August 2026 Agency Contact: Richard Meyer External Compliance Audit Manager Richard.Meyer@dshs.wa.gov
Finding Number: 2025-046 Finding: The Department of Social and Health Services, Home and Community Living Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Program: 93.775 – State Medicaid Fraud Control Units 93.777 –...
Finding Number: 2025-046 Finding: The Department of Social and Health Services, Home and Community Living Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Program: 93.775 – State Medicaid Fraud Control Units 93.777 – State Survey and Certification of Health Care Providers and Suppliers 93.778 – Grants to States for Medicaid 93.778 – COVID-19 Grants to States for Medicaid Compliance Requirement: Special Tests and Provisions – Provider Health and Safety Standards Questioned Costs: $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 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 address the most serious concerns. The Department has made efforts since fiscal year 2023 to address the backlog of complaints and recertification surveys, but resources had to be prioritized to handle 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 recertification timeframes. As of November 2025, the Department met compliance with the 15.9-month recertification survey interval measure based on the 2025 CMS State Performance Measurement Report. By August 2026, the Department expects to meet compliance with the 12.9-month statewide average. Prior Findings: The conditions noted in this finding were previously reported in findings 2024-079, 2023-079, and 2020-054. Completion Date: Estimated August 2026 Agency Contact: Richard Meyer External Audit Compliance Manager Richard.Meyer@dshs.wa.gov
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