Corrective Action Plans

Finding 20384 (2022-004)

Material Weakness 2022

MN

Allowable Costs / Cost Principles Material Weakness School Nutrition Programs

Finding Summary: During the course of our engagement, we noted instances where documentation was not retained supporting payroll expenditures and invoices were paid in an incorrect amount that was charged to the federal Child Nutrition Cluster program. Responsible Individuals: Shane Monson, Superint...

Finding Summary: During the course of our engagement, we noted instances where documentation was not retained supporting payroll expenditures and invoices were paid in an incorrect amount that was charged to the federal Child Nutrition Cluster program. Responsible Individuals: Shane Monson, Superintendent. Corrective Action Plan: The District will review and strengthen the controls surrounding the review and approval of allowable costs to ensure they are supported, approved of, and calculations are accurate. Anticipated Completion Date: June 30, 2023

View Audit 20655

Finding 20376 (2022-004)

Material Weakness 2022

The Be Kind People Project Foundation

AZ

Reporting Material Weakness Matching / Level of Effort / Earmarking

2022 ? 004 Material Weakness in Internal Control over Compliance with Preparation of Schedule of Expenditures of Federal Awards Condition: The Organization does not have an internal control system designed to provide for the preparation of the Schedule. The Schedule was not reviewed and required ad...

2022 ? 004 Material Weakness in Internal Control over Compliance with Preparation of Schedule of Expenditures of Federal Awards Condition: The Organization does not have an internal control system designed to provide for the preparation of the Schedule. The Schedule was not reviewed and required adjustments. Cause: The Organization had turnover and limited staffing available. Management?s Response and Corrective Action Plan: The organization was unprepared for the first time performing a single audit. Also, the information that was needed was issued later than optimal by the government for the reporting requirements. However, now that there is an understanding of the process, the schedule will be monitored monthly. The more consistent staffing will provide a better flow of communication with the approval process. The YTD schedules will be presented at quarterly Board Finance Committee meetings. Responsible Individuals: ? Accountability for understanding and management of the entire process ? Marcia Meyer, CEO ? Preparation of regular schedules during year ? Jennie Myers ? Preparation of quarterly schedule updates ? Jennie Myers ? Approval of quarterly schedules and presentation to Finance Committee ? Marcia Meyer (approval) and Jennie Myers ? Preparation of annual schedule in advance of the audit ? Jennie Myers ? Approval of annual schedule before submitting for audit ? Marcia Meyer Anticipated Completion Date: This will be implemented immediately and will be up to date by June 2023.

View Audit 19100

Finding 20375 (2022-003)

Material Weakness 2022

The Be Kind People Project Foundation

AZ

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.303

2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited st...

2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. Management?s Response and Corrective Action Plan: Changing the personnel involved has solved much of the problem, also the full awareness of what needs to be retained has also been explained to management. If/ when funds from federal sources are used, those expenditures will be reviewed monthly. Specifically, this will mean: ? Maintain EIDL-sourced funds in separate bank/ account. ? Have single authorization for any movement/ usage of funds in EIDL account. ? If/when funds from EIDL are used, have a written statement for purpose and documentation produced for use at the time of request. Responsible Individuals: ? Maintain separate account ? Marcia Meyer, CEO, in conjunction with Board Finance Committee ? Authorization for use of funds ? Marcia Meyer ? Maintenance of records for use ? JC Thompson ? Confirmation with use of funds per allowable uses per national guidelines ? Jennie Myers ? Reporting on monthly finance report ? Jennie Myers Anticipated Completion Date: This process is underway and will be visible at the fiscal year-end audit in June 2023.

View Audit 19100

Finding 20359 (2022-003)

Material Weakness 2022

Joseph's House and Shelter, Inc.

NY

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Finding 2022-003 ? General Oversite ? Material Weakness Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restruct...

Finding 2022-003 ? General Oversite ? Material Weakness Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restructuring the finance department. This could include allocating additional resources to hire additional employees, reallocation of responsibilities within the organization and less reliance on the contracted accounting services. View of Responsible Officials and Planned Corrective Actions: The Executive Director has worked with the Director of Grants and Finance to review and revise the agency?s accounting policies and procures. To ensure proper oversight, all procedures and reports will be reviewed by the Board?s Finance Committee, followed by a final review and approval of the Full Board of Directors of Joseph?s House & Shelter. Beginning in Q1 2022, agency leadership took necessary action to begin restructuring the Finance Department following a change in staffing with the contracted accounting service. In Q2 2022, the agency promoted a long-tenured staff member to the newly-created Director of Grants and Finance position, which separated and removed all finance duties from the Director of Administration. To support the Director of Grants and Finance, a full time Grants and Finance Specialist staff position was created in Q3 of 2022. The organization has scaled back reliance on the contracted accounting service and has ensured that all claims, with the implementation of personnel time tracking systems, are submitted through our Finance Department. We continue to use a contracted accounting service for higher-level accounting duties and for on-going advisement that supplements, instead of replaces, the work of internal staff. We are confident these changes have improved the agency?s ability to provide adequate management oversight in the financial reporting process. This was completed in Q2 of 2023.

View Audit 18957

Finding 20242 (2022-016)

Material Weakness 2022

Doral Academy of Nevada

NV

Reporting School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding Number: 2022-016 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of fin...

Finding Number: 2022-016 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of financial management in the School, Academica Nevada, the School?s management company, has filled all the open positions and realigned staff responsibilities to reduce individual workloads and provide additional oversight and review. The grant manager will reconcile all grants to ensure proper cutoff, with a secondary review performed by a member of management. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

View Audit 20771

Finding 20213 (2022-002)

Material Weakness 2022

West Central Nebraska Joint Housing Authority

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2022-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the inte...

Finding 2022-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 19649

Finding 20198 (2022-002)

Material Weakness 2022

Aurora Charter School

MN

Equipment & Real Property Management Procurement, Suspension & Debarment Material Weakness § 200.313

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION ? PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 ? EDUCATION STABILIZATION FUND, FEDERAL ALN 84.425 2022-002 Internal Control Over Compliance and Material Noncompliance With E...

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION ? PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 ? EDUCATION STABILIZATION FUND, FEDERAL ALN 84.425 2022-002 Internal Control Over Compliance and Material Noncompliance With Equipment and Real Property Management Requirements Finding Summary 2 CFR ? 200.313 (c)(1) and (d)(1) requires that Aurora Charter School (the School) obtain approval from the federal funding agency or pass-through agency prior to the purchase of equipment with federal funding. During our audit, we noted the School did not have sufficient controls in place within the COVID-19 ? Education Stabilization Fund federal program to assure compliance with federal equipment and real property management requirements, resulting in material noncompliance. Corrective Action Plan Actions Planned ? This condition and the resulting material noncompliance was caused by a misunderstanding of the cost threshold at which federal equipment and real property management compliance requirements must be applied, due to the School?s adopted internal capitalization threshold being lower than the federal threshold. The School intends to revise its internal capitalization threshold to align with the federal threshold, and to review its other control procedures relating to equipment and real property management requirements to ensure compliance for future federal awards expenditures. Official Responsible ? Matthew Cisewski, Executive Director. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The School agrees with this finding. Plan to Monitor ? The School?s Executive Director, Matthew Cisewski, will oversee the implementation of proposed corrective actions and verify that appropriate controls are in place and understood by individuals responsible for federal program oversite at the School to ensure future compliance with federal equipment and real property management requirements.

View Audit 28201

Finding 20150 (2022-001)

Material Weakness 2022

Labette Health Foundation, Inc.

KS

Student Financial Aid Subrecipient Monitoring Material Weakness

Corrective Action: A two-person team has been developed to ensure USDA terms and conditions are followed. Both team members will be responsible for reviewing and understanding the terms and conditions of the USDA loans, including the reporting requirements and applicable deadlines. Each team member ...

Corrective Action: A two-person team has been developed to ensure USDA terms and conditions are followed. Both team members will be responsible for reviewing and understanding the terms and conditions of the USDA loans, including the reporting requirements and applicable deadlines. Each team member will be assigned to complete a specific requirement and the other member will independently review and acknowledge prior to submission. Person Responsible: Janet Soper, VP/CFO, Labette Health (620} 820-5251 janets@labettehealth.com Proposed Completion Date: July 20, 2023

View Audit 24623

Finding 20113 (2022-002)

Material Weakness 2022

Mt. Si Senior Center

WA

Material Weakness Reporting Matching / Level of Effort / Earmarking

Views of responsible officials: The project coordinator at the property management firm oversees all recurring projects and ensures deadlines aren't missed. Digital reminders are used to ensure budgets are started and submitted on-time. USDA budgets are required to be submitted 90-days before the en...

Views of responsible officials: The project coordinator at the property management firm oversees all recurring projects and ensures deadlines aren't missed. Digital reminders are used to ensure budgets are started and submitted on-time. USDA budgets are required to be submitted 90-days before the end of the project's fiscal year if a rent increase is being requested and 60-days prior to the end of the fiscal year if no rent increase is requested. The USDA budget submission consists of a hard copy submission comprised of a budget using form 3560-7, a budget narrative, rent increase notice to tenant's (if applicable), and utility allowance calculations (if applicable). Additionally, the budget is submitted electronically through USDA's MINC system. Confirmation of the submission of the USDA budget is provided to the Executive Director and Accounting & HR Technician at Mt. Si Senior Center. Confirmation of the submission of the USDA budget is provided to the Executive Director and Accounting & HR Technician at Mt. Si Senior Center. Confirmation of the submission of the USDA budget is provided to the Executive Director and Accounting & HR Technician at Mt. Si Senior Center.

View Audit 21475

Finding 20101 (2022-001)

Material Weakness 2022

South Kitsap School District No. 402

WA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding ref number: 2022-001 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: Andrea Nokell 2689 Hoover Ave SE Port Orchard, WA 98366 360-874-7015 Corrective action th...

Finding ref number: 2022-001 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: Andrea Nokell 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 will obtain weekly certified payroll reports from all contractors and subcontractors performing public works projects funded with Federal funds. Anticipated date to complete the corrective action: Immediately.

View Audit 21474

Finding 19952 (2022-002)

Material Weakness 2022

New Community Employment Services Corporation

NJ

Cash Management Material Weakness Reporting

Finding Number - 2022-002 Planned Corrective Action - Internal controls have been strengthened to facilitate timely disbursement of student aid funds. Anticipated Completion Date - Complete Responsible Contact Person - Elizabeth Mbakaya, CFO of New Community Corporation (Managing Agent)

View Audit 17944

Finding 19943 (2022-005)

Material Weakness 2022

Floyd County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2022-005 Contact Person: Donald Lopp, Director of Operations and Planning Contact Phone Number: (812) 948.4110 Views of Responsible Official: Corrective Action As Director of Operations and Planning, the American Rescue Plan quarterly reports are submitted through the office. During the audi...

FINDING 2022-005 Contact Person: Donald Lopp, Director of Operations and Planning Contact Phone Number: (812) 948.4110 Views of Responsible Official: Corrective Action As Director of Operations and Planning, the American Rescue Plan quarterly reports are submitted through the office. During the audit, it appears eight of the ten audit items had the correct cumulative expenditure but those figures were not also applied to the current quarter expenditures. The US Treasury portal will not allow for the submission of the quarterly report unless the cumulative obligations and expenditures match. Description of Corrective Action Plan: Prior to submission, quarterly reports will be printed and reviewed by secondary staff in Office to review submission correctness. Anticipated Completion Date: This method will be instituted at the July 2023 quarterly report submission.

View Audit 23517

Finding 19892 (2022-001)

Material Weakness 2022

Jay County School Corporation

IN

Matching / Level of Effort / Earmarking Special Tests & Provisions Subrecipient Monitoring § 200.303

MATERIAL WEAKNESS 2022-001 Internal Control Over Program Compliance Recommendation: For future construction contracts financed by federal funds Jay School Corporation when required, should verify that subcontractors comply with prevailing wage requirements. Explanation of disagreement with audit fin...

MATERIAL WEAKNESS 2022-001 Internal Control Over Program Compliance Recommendation: For future construction contracts financed by federal funds Jay School Corporation when required, should verify that subcontractors comply with prevailing wage requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement a process to ensure all eligible projects requiring prevailing wage rate requirements are properly monitored. Name(s) of the contact person(s) responsible for corrective action: Shannon Current, Business Manager Planned completion date for corrective action plan: March 2023

View Audit 18111

Finding 19852 (2022-003)

Material Weakness 2022

Highlands School District

PA

Material Weakness Reporting Internal Control / Segregation of Duties

2022-003 Funding Source Reports and Expenditure Reporting Response Highlands School District agrees with the finding and the recommended procedures and is attempting to implement improvements over reporting.

View Audit 23491

Finding 19842 (2022-004)

Material Weakness 2022

Palm Beach County Housing Authority

FL

HUD Housing Programs Subrecipient Monitoring Eligibility

2022-004 ? Selection from the Waiting List Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to maintain the waiting list and track all correspondence with potential tenants. Explanation of disagreement w...

2022-004 ? Selection from the Waiting List Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to maintain the waiting list and track all correspondence with potential tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA acknowledges the continuing issues associated with this finding. The COVID-19 pandemic has placed unprecedented stress on companies across the country. The PBCHA was no exception. This stress negatively impacted the PBCHA?s management, workforce and operations which resulted in sudden changes in working arrangements, shortages due to workforce sickness, staffing vacancies and turnover all while dealing with increased housing demand due rising rental costs, and decreased housing supply and housing instability. Despite these challenges, the PBCHA remains strongly focused on continued and improved operations, increased compliance, and accountability. The PBCHA will continue to develop, train, and enforce procedures related to efficient waitlist management for families placed on the list for the HCV programs; the ongoing maintenance of the waiting lists; and selection of enough families from the list to maximize the PBCHA?s use of available funding. The PBCHA has elected to open its waiting lists beginning in June 2022 for its HCV programs and to leave lists open indefinitely to accurately depict the demand for affordable housing. This will require that PBCHA staff ae trained and annually comply with the procedures outlined in the Administrative Plan related to updating, removal and selection from the wait lists, admission, and eligibility, and that all steps are documented within the tenant file and agency business system accordingly. The PBCHA make decisions, develop strategies, implement policies/procedures, and utilize all available resources during this period of prevailing uncertainty and volatility. Any action taken to address the noted deficiency will be based on careful analysis, innovative thinking, restructuring, flexibility and/or revised strategies to adapt to everchanging business circumstances. Name(s) of the contact person(s) responsible for corrective action: Tyler Rasmussen. Carol Jones-

View Audit 23451

Finding 19841 (2022-003)

Material Weakness 2022

Palm Beach County Housing Authority

FL

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

2022-003 ? Rent Reasonableness Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to review tenant files to determine if a rent reasonableness has been performed. Explanation of disagreement with audit fin...

2022-003 ? Rent Reasonableness Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to review tenant files to determine if a rent reasonableness has been performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA acknowledges the continuing issues associated with this finding. The COVID-19 pandemic has placed unprecedented stress on companies across the country. The PBCHA was no exception. This stress negatively impacted the PBCHA?s management, workforce and operations which resulted in sudden changes in working arrangements, shortages due to workforce sickness, staffing vacancies and turnover all while dealing with increased housing demand due rising rental costs, and decreased housing supply and housing instability. Despite these challenges, the PBCHA remains strongly focused on continued and improved operations, increased compliance, and accountability. The agency will continue to develop, train, and enforce procedures to ensure rent reasonableness is performed on a timely basis as required by federal regulations and documentation is maintained in the tenant file. The agency utilizes an external resource to conduct rent comparison. The PBCHA will continue to train and instruct Housing Specialists on the responsibility to perform the rent reasonableness determination at the time of initial leasing, when there is an increase in rent to owner and at HAP contract anniversary if applicable under HUD rules and regulations. The PBCHA make decisions, develop strategies, implement policies/procedures, and utilize all available resources during this period of prevailing uncertainty and volatility. Any action taken to address the noted deficiency will be based on careful analysis, innovative thinking, restructuring, flexibility and/or revised strategies to adapt to everchanging business circumstances. Name(s) of the contact person(s) responsible for corrective action:

View Audit 23451

Finding 19840 (2022-002)

Material Weakness 2022

Palm Beach County Housing Authority

FL

Questioned Costs HUD Housing Programs Material Weakness

2022-002 ? HQS Enforcements Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management s...

2022-002 ? HQS Enforcements Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS housing inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA acknowledges the continuing issues associated with this finding. The COVID-19 pandemic has placed unprecedented stress on companies across the country. The PBCHA was no exception. This stress negatively impacted the PBCHA?s management, workforce and operations which resulted in sudden changes in working arrangements, shortages due to workforce sickness, staffing vacancies and turnover all while dealing with increased housing demand due rising rental costs, and decreased housing supply and housing instability. Despite these challenges, the PBCHA remains strongly focused on continued and improved operations, increased compliance, and accountability. The PBCHA continues to utilize its third-party vendor to complete all HQS inspections. The PBCHA will also utilize the technology available to make its HQS inspections and enforcement process as efficient as possible. This includes improved functionality within its new software system, new guidelines, and handheld technology and RVI methods as appropriate. The PBCHA make decisions, develop strategies, implement policies/procedures, and utilize all available resources during this period of prevailing uncertainty and volatility. Any action taken to address the noted deficiency will be based on careful analysis, innovative thinking, restructuring, flexibility and/or revised strategies to adapt to everchanging business circumstances. Name(s) of the contact person(s) responsible for corrective action: Tyler Rasmussen, Carol Jones- Gilbert

View Audit 23451 Questioned Costs: $1

Finding 19839 (2022-001)

Material Weakness 2022

Palm Beach County Housing Authority

FL

HUD Housing Programs Subrecipient Monitoring Eligibility

Eligibility 2022-001 ? Eligibility Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in ac...

Eligibility 2022-001 ? Eligibility Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and unit the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA acknowledges the continuing issues associated with this finding. The COVID-19 pandemic has placed unprecedented stress on companies across the country. The PBCHA was no exception. This stress negatively impacted the PBCHA?s management, workforce and operations which resulted in sudden changes in working arrangements, shortages due to workforce sickness, staffing vacancies and turnover all while dealing with increased housing demand due rising rental costs, and decreased housing supply and housing instability. Despite these challenges, the PBCHA remains strongly focused on continued and improved operations, and increased compliance and accountability. The PBCHA will continue to utilize all available resources to recruit, retain and train HCVP staff on the HCV program guidelines, to include training to determine what is included and excluded from annual income, how to identify and calculate assets, correctly calculate adjusted income by applying the HUD defined allowances and expenses, recognize the requirements for verification of income, allowances, and expenses and calculate total tenant payment and housing assistance payment (HAP). The PBCHA make decisions, develop strategies, implement policies/procedures, and utilize all available resources during this period of prevailing uncertainty and volatility. Any action taken to address the noted deficiencies will be based on careful analysis, innovative thinking, restructuring, flexibility and/or revised strategies to adapt to everchanging business circumstances. Board of Commissioners Paul Dumars, Chairman Phyllis Choy, Vice Chair Digna Mejia Charlie Fetscher CEO and Executive Director Carol Jones-Gilbert 3432 West 45th Street West Palm Beach, Florida 33407 Office: (561) 684-2160 ext. 104 Mobile: (561) 628-9387 Fax: (561) 455-9965 Name(s) of the contact person(s) responsible for corrective action: Tyler Rasmussen, Carol Jones- Gilbert

View Audit 23451

Finding 19812 (2022-011)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with quality assurance program requirements to ensure materials conformed to approved plans and specifications, and that only qualified personnel performed testing for projects...

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with quality assurance program requirements to ensure materials conformed to approved plans and specifications, and that only qualified personnel performed testing for projects funded by the Highway Planning and Construction Cluster. Questioned Costs: CFDA # 20.205 20.205 COVID-19 20.219 20.224 Amount $0 Status: Corrective action in progress Corrective Action: The Department is committed to ensuring that our grant programs comply with federal regulations related to quality assurance (QA) requirements and safeguarding that materials and workmanship conform to approved plans and specifications through testing, inspections, or certifications. The Department continues to work closely with the Federal Highway Administration (FHWA) on the QA program and has received positive feedback on the strength of the program. In addition, the Department is currently investing in the Unifier software to replace separate QA legacy systems, which will allow shared data and provide built-in controls to help prevent the issues identified in the audit. Depending on funding and programming times, the Department estimates Unifier to be online for the QA program within five years. To address the audit recommendations, the Department?s Construction Division will examine current policies and procedures/practices related to the audit issues. The Department will: ? Update policies and procedures, including the Department?s Construction Manual (M46-01), as needed to ensure staff practices meet federal regulations. Updates will also include other clarifications to address documentation and evidence of compliance, and a reasonable level of controls regarding materials testing, inspections, certification, acceptance, and tester certifications. ? Obtain approval of updates to the Construction Manual from the FHWA. ? Communicate changes in policies and procedures to division staff and stakeholders. ? Provide training to Project Engineering Office staff to emphasize QA program requirements. The conditions noted in this finding were previously reported in findings 2021-011, 2020-017 and 2019-019. Completion Date: Estimated June 2024 Agency Contact: Jesse Daniels External Audit Liaison PO Box 47320 Olympia, WA 98504-7320 (360) 705-7035 danielje@wsdot.wa.gov

View Audit 23129

Finding 19809 (2022-008)

Significant Deficiency 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Washington State Department of Transportation did not have adequate internal controls to ensure supervisors reviewed and approved payroll journals for the Highway Planning and Construction Cluster. Questioned Costs: Assistance Listing # 20.205 20.205 COVID-19 20.219 20.224 Amoun...

Finding: The Washington State Department of Transportation did not have adequate internal controls to ensure supervisors reviewed and approved payroll journals for the Highway Planning and Construction Cluster. Questioned Costs: Assistance Listing # 20.205 20.205 COVID-19 20.219 20.224 Amount $0 Status: Corrective action in progress Corrective Action: The Department is committed to ensuring adequate internal controls are established for processing payroll journals. Currently, the Department: ? Sends payroll journals electronically via Adobe Acrobat Sign on day four of payroll processing. ? Generates system automated emails, which are sent to the reviewer each day the journal is unsigned. ? Reconciles unsigned payroll journals and will follow up with responsible staff. To further improve controls over timely approval and return of payroll journals, the Department will: ? Continue to review existing internal controls to assess their effectiveness and make improvements as needed. ? Review the Payroll Manual to ensure directions, guidelines, and expectations around the payroll journal approval are clearly defined. ? Evaluate the appropriateness of establishing a timeline for returning signed payroll journals for incorporation into the Payroll Manual. Completion Date: Estimated June 2024 Agency Contact: Jesse Daniels External Audit Liaison PO Box 47320 Olympia, WA 98504-7320 (360) 705-7035 danielje@wsdot.wa.gov

View Audit 23129

Finding 19717 (2022-061)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

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

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 partially concurs with the finding. The Authority has received guidance from the Centers for Medicare & Medicaid Services (CMS) and will adjust the state plan based on CMS requirements. Per CMS guidance, this adjustment will not include separately listing the methods and procedures it uses to safeguard against unnecessary utilization of care and services. The Authority does not concur with the auditor?s conclusion regarding its statewide surveillance and utilization control program not meeting federal program integrity requirements. The Authority?s program meets CMS standards and requirements and provides reasonable oversight. The Authority will update its policies and procedures related to the program. The Authority concurs that the two providers of the Program of All-inclusive Care for the Elderly (PACE) were not monitored for their compliance with the False Claims Act (FCA) during the fiscal year. The Department of Social and Health Services (DSHS) manages the contracts for the PACE program, but payments to these providers are routed through the Authority?s ProviderOne system. The process for PACE provider monitoring has been clarified with DSHS who is responsible for providing FCA oversight for these contracts. The conditions noted in this finding were previously reported in findings 2021-050, 2020-047, 2020-048, 2019-052, 2019-053 and 2018-047. Completion Date: Estimated December 2023 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

View Audit 23129

Finding 19716 (2022-060)

Material Weakness 2022

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 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 Cost...

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 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority does not agree it did not comply with federal requirements related to audits of inpatient hospitals. The Authority performs the following procedures: Cost report data for rate setting: ? Audits Medicaid cost report schedules and supporting documentation used for the Certified Public Expenditure Program. ? Audits critical access hospital data and uses final audited Medicare cost reports for settlement. ? Reviews and audits hospital cost reports using the ratio of costs-to-charges payment method. Hospital billings: ? Annual audits of hospital billings. Other financial and statistical records: ? Audits disproportionate share hospital reimbursements. The Authority concurs that documentation of the different hospital audits performed could be more clearly defined and will formalize procedures related to the conduct of the required audits. The conditions noted in this finding were previously reported in findings 2021-051 and 2020-049. Completion Date: Estimated December 2023 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

View Audit 23129

Finding 19715 (2022-059)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid Program. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0...

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with federal provider eligibility requirements 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 complete Corrective Action: The Department concurs with the finding. As of June 2022, individual providers are no longer contracted through the Department and now contract with Consumer Direct of Washington. As a result of this change, this type of error will not occur for individual providers moving forward. As of March 2023, the Department reviewed all providers in the monthly exclusion report. The Department verified that the provider identified in the finding for missing enrollment documentation was never employed and did not receive any payments. Completion Date: March 2023 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

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Finding 19714 (2022-058)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Special Tests & Provisions Procurement, Suspension & Debarment

Finding: The Department of Social and Health Services did not have adequate internal controls over False Claims Act requirements. 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:...

Finding: The Department of Social and Health Services did not have adequate internal controls over False Claims Act requirements. 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 concurs with the finding. As of April 2023, the Department: ? Generated and tested a new internal report that will include all Aging and Long-Term Support Administration and Developmental Disabilities Administration Medicaid providers. ? Mailed correspondence to the one provider who was missing documentation to request the False Claims Act (FCA) attestation, policy, and procedures. ? Updated process to include follow up with providers monthly until the FCA attestations and other documents are received. By October 2023, the Department will ensure all outstanding FCA attestations and documents are returned to ensure compliance with the FCA requirement. Completion Date: Estimated October 2023 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 23129

Finding 19713 (2022-057)

Material Weakness 2022

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 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 not all complaint investigations were initiated within the required timeframes. However, the Department does not agree that noncompliance was due to inadequate internal controls. Residential Care Services (RCS) has effectively used current internal controls since fiscal year 2017 when we received the State Auditor?s Office Stewardship Award related to this audit area. Compliance with required complaint investigation timeframes decreased due to an increase in complaints from the previous fiscal year that were assigned for investigation. In addition, the effects of the COVID-19 pandemic increased staff vacancy rates to 24% due to exposure, illness, and staff resignation caused by vaccination mandates. By December 2023, the Department will: ? Extend the contract with Health Care Management Solutions to assist with surveys. This will allow RCS staff to return the focus to complaint investigations, complaint backlog, and compliance with required investigation timeframes. ? Condense and streamline Nursing Home Surveyor Training to enable staff to complete survey training faster than previous timeframes. ? Provide training to staff that were recently hired to fill the vacant positions to ensure compliance with investigation timeframes. The conditions noted in this finding were previously reported in finding 2021-054. Completion Date: Estimated December 2023 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 23129

Corrective Action Plans

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