Corrective Action Plans

Finding 16544 (2022-001)

Material Weakness 2022

ID

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Finding 2022-001 Finding Summary: The Hospital excluded certain amounts from the amounts reported as "2021 actuals (Calendar Year)" patient care revenue within the Period 4 Department of Health and Human Services report submission process. Responsible Individuals: John Hennessy, CFO Corrective Acti...

Finding 2022-001 Finding Summary: The Hospital excluded certain amounts from the amounts reported as "2021 actuals (Calendar Year)" patient care revenue within the Period 4 Department of Health and Human Services report submission process. Responsible Individuals: John Hennessy, CFO Corrective Action Plan: The cause of the finding was due to management's review of the schedule did not identify that there was an adjustment to net patient revenue that was not incorporated within the 2021 actuals. Going forward, management will reconcile the internal generated financials used for quarterly reporting with the audited financials to ensure the schedule used includes all adjustments to net patient revenue. Anticipated Completion Date: September 28, 2023 Federal Agency Name: Department of Health and Human Services Program Name: COVJD-19 Provider Relief Funds and American Rescue Plan (ARP) Rural Distribution CFDA #93.498

View Audit 20452

Finding 16537 (2022-001)

Material Weakness 2022

New Brunswick Theological Seminary of the Reformed Church in America

NJ

Student Financial Aid Reporting Special Tests & Provisions

Views of Responsible Officials and Corrective Action Planned: The Seminary hired a third-party financial aid servicer, Financial Aid Services, LLC (?FAS?) who will do the enrollment reporting as part of their contract. The FAS contract was signed May 2022 for the upcoming fiscal year 2022 to 2023. T...

Views of Responsible Officials and Corrective Action Planned: The Seminary hired a third-party financial aid servicer, Financial Aid Services, LLC (?FAS?) who will do the enrollment reporting as part of their contract. The FAS contract was signed May 2022 for the upcoming fiscal year 2022 to 2023. This contract was approved by the Administrative Council in May 2022. The Seminary?s current part-time financial aid coordinator sent out the April 2022 enrollment roster which included student status changes on October 17, 2022.

View Audit 20434

Finding 16529 (2022-001)

Material Weakness 2022

Sea Mar Community Health Center and Subsidiaries

WA

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Finding 2022-001 Sea Mar will retrain medical, dental and behavioral health department staff at all sites who conduct and/or oversee the patient registration and income verification process. This includes Health Center Administrators, Front Desk Supervisors, Dental Supervisors, Financial Specialist...

Finding 2022-001 Sea Mar will retrain medical, dental and behavioral health department staff at all sites who conduct and/or oversee the patient registration and income verification process. This includes Health Center Administrators, Front Desk Supervisors, Dental Supervisors, Financial Specialists and Receptionists. This training will be conducted via Relias (web-based training and testing). This training will be required for all staff including new hires to ensure compliance and consistency. A competency test will be administered after the training, which requires a score of I 00% to pass. If an employee does not pass the competency test, they will be retrained and will retake the test. We will track and run reports for all staff that are required to complete these tasks to ensure compliance. This log will demonstrate that staff at the sites were trained and have passed the competency test. Sea Mar will conduct an audit to determine the accuracy of income verifications. The audit will select a random sample of patients to test and verify accuracy and completeness. Sea Mar has set a goal to achieve accuracy percentage of 95%-100% and will conduct monthly audits to monitor accuracy and improvement. Sea Mar will also implement a process that will require supervisors to review and sign off on employee's income verifications to ensure they are accurate. Supervisors will be expected to ensure this process is being conducted accurately at their sites and to retrain staff who are not accurately verifying income. This review and sign off process will be verified during the quarterly audit. The quarterly audit will also identify sites and staff who need additional training. The contact person for the corrective action plan is Sea Mar's Chief Compliance Officer, Kristina Hoeschen, Kristina Hoeschen@seamarchc.org ,and the anticipated completion date of November 30, 2022.

View Audit 20416

Finding 16323 (2022-004)

Material Weakness 2022

West Holt Memorial Hospital

NE

Special Tests & Provisions Cash Management Material Weakness § 200.327 § 200.328

Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CF...

Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a reserve fund at specified balance levels. Condition: During 2022, the accounts that represented the reserve fund had a balance below that required by the loan resolution agreements and required deposits were not being made to restore the balances to required levels. Planned Corrective Action: Management agrees with the finding and will deposit required amounts into the reserve fund. Planned Completion Date: Ongoing Person Responsible: Jeremy Bauer, CEO

View Audit 22832

Finding 16316 (2022-002)

Significant Deficiency 2022

Chisholm School District I-42

OK

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

Reference Number: 22-02 Name of Award ? Project Number (794, 628, 770) (Federal Findings) Condition/Finding: The District's final expenditure reports with the Oklahoma State Department of Education and Oklahoma Cost Accounting System (OCAS), did not match the actual allowable expense for their p...

Reference Number: 22-02 Name of Award ? Project Number (794, 628, 770) (Federal Findings) Condition/Finding: The District's final expenditure reports with the Oklahoma State Department of Education and Oklahoma Cost Accounting System (OCAS), did not match the actual allowable expense for their program. Three programs (794, 628, 770) had OCAS coding errors when final reports were submitted to the Oklahoma State Department of Education. Corrective steps that have already been implemented and/or the steps that will be implemented: All OCAS data, both receiving and expenditures, will be correct and accurate. All OCAS data involving Federal Programs will be reported correctly and accurately to the Oklahoma State Department of Education. Completion Date: Immediately The plan for monitoring adherence to the corrective action plan: All Chisholm Public Schools central office personnel involved with purchase orders, and OCAS data, will seek professional development and training to improve professionally. Additionally, all Chisholm Public Schools central office personnel will work collaboratively to ensure that all OCAS data is correct and accurate on an ongoing basis. Finally, all finalized OCAS data will be completely accurate when submitting to the Oklahoma State Department of Education. If warranted, reasons why the district does not consider a Corrective Action necessary. Superintendent's Signature Date

View Audit 21640

Finding 16113 (2022-015)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Office of Financial Management did not have adequate internal controls over and did not comply with reporting requirements for the Coronavirus Relief Fund. Questioned Costs: Assistance Listing # 21.019 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: ...

Finding: The Office of Financial Management did not have adequate internal controls over and did not comply with reporting requirements for the Coronavirus Relief Fund. Questioned Costs: Assistance Listing # 21.019 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Office had controls in place for the Coronavirus Relief Fund (CRF) reporting requirements to ensure reported amounts, including corrections or adjustments made during the reporting period, were properly tracked and documented for subsequent reporting cycles. The Office performed continual monitoring of CRF expenditures to ensure the total grant expenditures reported were complete and accurate. The Office?s Statewide Accounting staff took over the responsibility for reviewing and certifying cycle 8 to 10 reports. Each report was reviewed prior to submission and documentation of the review was adequately maintained. The review ensured amounts submitted on the reports reconciled to supporting documentation provided by agencies at the time the reports were prepared. However, system issues in the federal reporting system created challenges in documenting changes to the templates as errors appeared and were subsequently corrected for the reporting cycle. For the final cycle 10 report, the Office ensured the cumulative amounts on the CRF report were supported by the underlying accounting records and performed a complete reconciliation of expenditures to the totals reported for each expenditure category. All revisions and resubmissions of the final report were completed in cycle 10. No additional revisions are required at this time. The final report was submitted in January 2023 and the grant is in its closeout phase. The Office considers this issued resolved. The conditions noted in this finding were previously reported in finding 2021-014. Completion Date: January 2023 Agency Contact: Brian Tinney Statewide Accounting Director PO Box 43127 Olympia, WA 98504-3127 (564) 999-1781 brian.tinney@ofm.wa.gov

View Audit 23129

Finding 16107 (2022-006)

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 Employment Security Department did not have adequate internal controls over and did not comply with federal requirements to conduct case reviews for the Benefit Accuracy Measurement program of the Unemployment Insurance program in a timely manner. Questioned Costs: Assistance Listin...

Finding: The Employment Security Department did not have adequate internal controls over and did not comply with federal requirements to conduct case reviews for the Benefit Accuracy Measurement program of the Unemployment Insurance program in a timely manner. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: Historically, the Benefit Accuracy Measurement (BAM) unit has been challenged to maintain full levels of staffing. Staff turnover, long training requirements, and unique skill sets make these positions difficult to maintain. The BAM Unit currently has one vacancy and is expected to have more with upcoming retirements. The Department is currently in a hiring freeze for Unemployment Insurance administrative funding, furthering the challenge to fully staff the unit and meet program requirements. Once the hiring freeze is lifted, the unit will fill the vacant position. The Department anticipates the unit will meet federally mandated timelines for case reviews when the unit is fully staffed and trained. The Department continues to partner and frequently communicate with the U.S. Department of Labor (USDOL) Regional Offices to discuss staffing and training models. The Quality Assurance Manager and the Case Review Supervisor are committed to routinely monitor caseload, workload, and the overall assurance of meeting the BAM operations performance goals and measures as set forth by USDOL. The conditions noted in this finding were previously reported in findings 2021-005 and 2020-011. Completion Date: Estimated June 2024 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 23129

Finding 16106 (2022-005)

Significant Deficiency 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Employment Security Department did not have adequate internal controls to ensure it submitted accurate monthly reports for the Unemployment Insurance program. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Correctiv...

Finding: The Employment Security Department did not have adequate internal controls to ensure it submitted accurate monthly reports for the Unemployment Insurance program. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department implemented a secondary review of the monthly ETA 9055 performance report to verify the data pulled from source documentation is accurately represented prior to submitting to the federal reporting system. Completion Date: May 2023 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 23129

Finding 16104 (2022-004)

Significant Deficiency 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Health did not have adequate internal controls to ensure payments to providers were allowable, met cost principles, and were within the period of performance for the Special Supplemental Nutrition Program for Women, Infants, and Children. Questioned Costs: Assistance L...

Finding: The Department of Health did not have adequate internal controls to ensure payments to providers were allowable, met cost principles, and were within the period of performance for the Special Supplemental Nutrition Program for Women, Infants, and Children. Questioned Costs: Assistance Listing # 10.557 10.557 COVID-19 Amount $0 Status: Corrective action not taken Corrective Action: The Department disagrees with the auditor?s assessment of a significant deficiency in internal controls over the consolidated contract provider payment process for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The Department has established processes in place to ensure payments are allowable, meet cost principles, and comply with period of performance requirements for the WIC program. These include: ? Perform annual review and approval of detailed subrecipient budgets. ? Compare invoice amounts to budgeted amounts for reasonableness before payment approval. ? Provide subrecipients regular technical assistance and training on applicable policies related to fiscal and programmatic processes. ? Conduct biennial program and fiscal monitoring visits to subrecipients as part of the Department?s monitoring procedures. In addition, the WIC program has monitoring controls in place and evidence of review at the program level. The quality assurance program staff maintain a detailed payment log that documents review and approval and details any amounts that need to be withheld until issues with invoice support are resolved. These reviews are to be completed within the 10-day period before payment is released. Similar conditions noted in this finding were previously reported in finding 2021-004. Completion Date: Not applicable Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov

View Audit 23129

Finding 16082 (2022-002)

Significant Deficiency 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions § 200.1

Finding: The University of Washington did not have adequate internal controls to ensure key personnel commitments specified in grant proposals or awards were met. Questioned Costs: Assistance Listing # Various Amount $0 Status: Corrective action in progress Corrective Action: The Univer...

Finding: The University of Washington did not have adequate internal controls to ensure key personnel commitments specified in grant proposals or awards were met. Questioned Costs: Assistance Listing # Various Amount $0 Status: Corrective action in progress Corrective Action: The University has established internal controls to ensure compliance with key personnel program requirement through time and effort certifications, project reporting processes, and budget reconciliation requirements. Additionally, the University offers multiple training courses to research administrators and principal investigators (PI) on management of sponsored awards. The University agrees there are areas for improvement over staff and PI training, and resources available to monitor contribution and documentation of committed levels of time and effort. The University will implement the following improvements: ? Update training materials and provide additional training to PIs and key personnel on: o Documentation of time and effort. o Prior approval requirements for reductions in time and effort. ? Update guidance and instructions for time and effort certifications to ensure all personnel involvement in various grant programs is properly accounted for during the certification process. ? Develop exception reports to provide additional oversight to monitor deviations from committed time and effort for PIs and key personnel. Completion Date: Estimated February 2024 Agency Contact: Erick Winger Controller 4300 Roosevelt Way NE Seattle, WA 98195 (206) 543-5322 erickw@uw.edu

View Audit 23129

Finding 16035 (2022-054)

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

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with managed care financial audit requirements. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action complete Corrective Action: The Authority implemented policies and procedures and established a process to: ? Collect audited financial reports annually from managed care organizations. ? Conduct audits of encounter and financial data no less than once every three years. Additionally, the Authority amended managed care contract language to include the following: ? Required managed care organizations to submit audited financial reports annually beginning in fiscal year 2023. ? Directed managed care organizations to follow the required timing and procedures for submitting audited financial reports. ? Clarified that failure to submit reports is sanctionable. The Authority also conducted an encounter validation audit and is conducting a financial report validation audit. These audits are completed in a frequency outlined in federal regulations. The conditions noted in this finding were previously reported in finding 2021-048. Completion Date: May 2022 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 16020 (2022-004)

Material Weakness 2022

Harry S. Truman Community Development Corporation

MO

Subrecipient Monitoring Material Weakness

2022-04 Recommendation: The Organization should have a process for determining the proper valuation of donations depending upon the terms of the donation and date of receipt of the donation. Corrective Action We acknowledge that there is currently not a sufficient process in place Planne...

2022-04 Recommendation: The Organization should have a process for determining the proper valuation of donations depending upon the terms of the donation and date of receipt of the donation. Corrective Action We acknowledge that there is currently not a sufficient process in place Planned: to ensure that the value of the organization?s note receivable balances are properly recorded. A policy will be implemented to review the accounting records to ensure that the value of the organization?s note receivables balance properly recorded now that the Organization has staff and an outsourced accounting firm with the knowledge and skills to fulfill this need. Implementation This action plan is for the entity to adopt a policy to regularly review the accounting records and evaluate the value of promissory notes receivable Date: to determine current value of note and review evaluate any possible contingencies of the receivable. This policy is planned to be in place by 12/31/23.

View Audit 19588

Finding 16019 (2022-003)

Material Weakness 2022

Harry S. Truman Community Development Corporation

MO

Subrecipient Monitoring Material Weakness

2022-03 Recommendation: The Organization review its transactions for repairs and maintenance and obtain the fixed assets depreciation schedule in order to properly record real estate transactions. The Organization should review its transactions invoiced but not paid prior to year-end in order to p...

2022-03 Recommendation: The Organization review its transactions for repairs and maintenance and obtain the fixed assets depreciation schedule in order to properly record real estate transactions. The Organization should review its transactions invoiced but not paid prior to year-end in order to properly record accrued liabilities. Corrective Action We acknowledge that there is currently not a sufficient process in place Planned: to ensure that capital expenditures and accounts payable are properly recorded. A policy will be implemented to review the accounting records to ensure that capital expenditures and accounts payable are properly recorded now that the Organizations has staff and an outsourced accounting firm with the knowledge and skills to fulfill this need. Implementation This action plan is for the entity to adopt a policy to review repairs and Date: maintenance activity on a regular basis to determine what amounts need to be capitalized as a fixed asset to ensure proper treatment of activity. The entity will adopt a policy to review expenses invoiced but not yet paid to determine what amounts need to be accrued to ensure proper treatment of activity. This will be implemented by the entity by 12/31/23.

View Audit 19588

Finding 16018 (2022-002)

Material Weakness 2022

Harry S. Truman Community Development Corporation

MO

Subrecipient Monitoring Material Weakness

2022-02 Recommendation: The Organization should obtain a legally binding document prior to recording a debt extinguishment. Corrective Action Planned: We acknowledge and will receive formal documentation that will legally forgive the debt or formalize the promissory note Anticipated ...

2022-02 Recommendation: The Organization should obtain a legally binding document prior to recording a debt extinguishment. Corrective Action Planned: We acknowledge and will receive formal documentation that will legally forgive the debt or formalize the promissory note Anticipated This action plan is ongoing as legally binding debt documentation is Implementation being obtained with continued oversight by management and the Board Date: of Directors.

View Audit 19588

Finding 16017 (2022-001)

Material Weakness 2022

Harry S. Truman Community Development Corporation

MO

Subrecipient Monitoring Material Weakness

2022-01 Recommendation: The Organization should have a process for reviewing prior year balances in their Quickbooks Online accounting software to ensure that they match to the audited financial statements. The organization should refrain from making changes to their financials once financial stat...

2022-01 Recommendation: The Organization should have a process for reviewing prior year balances in their Quickbooks Online accounting software to ensure that they match to the audited financial statements. The organization should refrain from making changes to their financials once financial statements for the period under audit have been issued and closed. Corrective Action Planned: We acknowledge that there is currently not a sufficient process in place to review Quickbooks Online balances. A policy will be implemented to review prior year Quickbooks Online balances to ensure that they match to the audited financial statements now that the Organization has a Fiscal Officer with the knowledge and skills to fulfill this need. Anticipated This action plan is for the entity to adopt a policy to review Quickbooks Implementation Online balances at the end of each year to ensure that they tie to the Date: audited financial statements issued at the end of the year. This will be implemented by the entity by 6/30/23.

View Audit 19588

Finding 15995 (2022-051)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Student Financial Aid

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with reporting requirements for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Cor...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with reporting requirements for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department acknowledges that errors were made in the quarterly reports submitted during the audit period. The errors were identified by the Department and corrected in October 2022. The Department understands accuracy in reporting is vital. To address the audit finding and recommendations, the Department took the following corrective actions: ? The lead worker established three meetings each quarter with the Cost Allocation and Grants Director for processing the quarterly reports: o A pre-meeting to discuss the reporting requirements, o A meeting during the reporting process to review the final report prior to submission, and o A post reporting meeting to discuss any concerns encountered during the reporting process. ? Implemented a data verification process by management prior to submission of the quarterly reports. The Department is committed to improving internal controls over grant management activities and will continue to properly follow the grantor?s published instructions when completing the quarterly reports. Completion Date: October 2022 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 23129

Finding 15994 (2022-050)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure group care facility employees had cleared background checks before having unsupervised access to children. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Stat...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure group care facility employees had cleared background checks before having unsupervised access to children. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department partially concurs with the finding. The Department is committed to ensuring the health, safety, and well-being of all children in our care. As stated in the Effect of Condition on the audit finding, the auditors found all group care facility staff sampled during the audit had a cleared background check prior to working in the facility. While the Department agrees the use of definitions such as ?effective date? and ?start date? in FamLink could be misleading, the Department does not concur internal controls were not adequate to ensure group care facility employees had cleared background checks before having unsupervised access to children. The Department is confident that all staff who work with children and youth have cleared background checks. Effective April 1, 2023, the Department implemented a new process for processing background checks for group care facilities to strengthen internal controls, documentation, and clarification on the ?effective date.? The updated process is outlined below: ? A new form was created with clear instructions for the group care facilities to provide the applicant/employee information, including the background check confirmation code, directly to the Department?s Background Check Unit (BCU). ? The BCU works with the applicant/employee through the fingerprint background check process. ? The results are sent directly to the BCU at which time they complete a child abuse/neglect history check and, if needed, a suitability assessment. The BCU documents the results in FamLink with the date the background check is completed. ? The BCU emails the results to the group care facility and the Department?s Licensing Division (LD) group. If the applicant/employee is cleared and is not a renewal, LD staff adds the applicant/employee to the group care facility in FamLink with the clearance information attached. Completion Date: April 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 23129

Finding 15992 (2022-048)

Significant Deficiency 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 St...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action in progress Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. In response to the auditor?s recommendations, the Department will work with the Financial and Business Services Division and Foster Care Program to review the fiscal monitoring procedures to ensure payments to providers for travel and family visits are allowable and adequately supported. The conditions noted in this finding were previously reported in finding 2021-040. Completion Date: Estimated December 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 23129

Finding 15991 (2022-047)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Children, Youth, and Families did not have adequate controls over and did not comply with certain requirements of its Public Assistance Cost Allocation Plan. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Correct...

Finding: The Department of Children, Youth, and Families did not have adequate controls over and did not comply with certain requirements of its Public Assistance Cost Allocation Plan. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Action: The Department concurs with the finding and is committed to improving internal controls. During July through September 2021, the first three months of the audit period, the Department did not have adequate staffing levels to maintain the business processes for the Public Assistance Cost Allocation Plan (PACAP) cost base for administrative charges. Available staff focused on grant reconciliations and close-out of the prior fiscal year financial transactions. In October 2021, the Department began updating the monthly workbooks in accordance with the approved PACAP. To address the finding and audit recommendations, the Department: ? Reviewed the written base edit form procedures with staff. ? Added reminders for base edit entries to the Cost Allocation and Grants Management Unit calendar. Completion Date: April 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 23129

Finding 15981 (2022-037)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

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

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure staff properly considered the income information obtained from data matching when determining client eligibility and benefits for the Temporary Assistanc...

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure staff properly considered the income information obtained from data matching when determining client eligibility and benefits for the Temporary Assistance for Needy Families program. Questioned Costs: Assistance Listing # 93.558 Amount $0 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The Department has established processes in place to ensure income information is properly considered during client eligibility and benefits determination for the Temporary Assistance for Needy Families (TANF) Program. During eligibility determination at application intake, the eligibility worker: ? Interviews the client to determine income. ? Compares client reported information and cross matches against the Income Eligibility and Verification System (IEVS) per the Code of Federal Regulations (CFR). ? Resolves discrepancies for all new or previously unverified information received. ? Uses the information to determine if the client income is below the maximum earned income limits for TANF per WAC 388-478-0035. ? Verifies all circumstances as required in WAC 388-490-0005 and follows requirements when discrepancies exist, which include taking appropriate actions if the information is questionable, confusing, or outdated. The Department utilizes Spider, which is a tool that combines several different data matches including IEVS. In addition, the Department uses templates to appropriately and comprehensively document the eligibility determination to ensure consistency, accuracy, and that lean processes are followed. ? The Earned Income Template o Addresses income received within 30 days of the application date and any discrepancies found between the case record, online verification systems, previously projected income, and income type. o Does not require documentation if there is no income reported and when no discrepancy is found in cross matches. ? The Final Narrative Template o Includes completing check boxes to document types of cross matches reviewed during application intake and a summary of the transactions that occurred. In all seven exceptions identified by the auditors, the client?s situation did not require the eligibility workers to use the Earned Income Templates due to: ? No income reported. ? No income found in IEVS and other cross matches. ? No discrepancies. ? No changes within 30 days. The eligibility workers did create documentation using the Final Narrative Template for all seven cases with notation stating: ?Reviewed the following system(s): Spider.? All these actions were consistent and aligned with the Department?s "Standard Remarks and Narrative Documentation? procedures. Alerts are not generated for all income fluctuations but as appropriate when a review and potential action is required. This is to minimize creating unnecessary alerts which would take staff time away from other required and mission-critical actions. The Department asserts that the system is working as designed, which is evidenced by the fact that the Department accurately determined eligibility in all seven cases identified as exceptions by the auditors. The Department will continue to: ? Review IEVS information at application intake and verify and document any discrepancies between what is reported by the household and what is shown in the cross matches. ? Use templates to ensure documentation supports the eligibility decisions. ? Generate alerts when an applicant is budgeted with zero income, but the IEVS data match shows income. ? Use the final narrative documentation template, that includes check boxes, to notate cross matches reviewed during application intake. Completion Date: Not applicable Agency Contact: Rick Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 23129

Finding 15976 (2022-034)

Material Weakness 2022

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Reporting Equipment & Real Property Management

Finding: The Department of Health did not have adequate internal controls over and did not comply with reporting requirements for the Epidemiology and Laboratory Capacity for Infectious Diseases program. Questioned Costs: Assistance Listing # 93.323 93.323 COVID-19 Status: Corrective action...

Finding: The Department of Health did not have adequate internal controls over and did not comply with reporting requirements for the Epidemiology and Laboratory Capacity for Infectious Diseases program. Questioned Costs: Assistance Listing # 93.323 93.323 COVID-19 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. For the two reports on which the auditors took exceptions, the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) program did discover the errors after the original reports were submitted. The Department notified the Centers for Disease Control and Prevention (CDC) about the reporting errors in February 2022, which was within the reporting period. However, due to a technical issue, the federal reporting system would not allow ELC program staff to input edits to the reports for the months of July through October 2021. After a discussion with CDC, program staff were advised to submit the corrected data of the previous reports via email, which was subsequently accepted by the grantor and the issue was resolved. The Department agrees there needs to be evidence of documented reviews of reports and is implementing steps to ensure review and approval of reports are well documented and retained before final submission to the federal grantor. Completion Date: Estimated December 2023 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov

View Audit 23129

Finding 15938 (2022-001)

Material Weakness 2022

Syracuse Model Neighborhood Facility, Inc.

NY

Material Weakness Reporting Internal Control / Segregation of Duties

Material Weakness 2022-001 Bank Statement Reconciliations Contact Person Responsible for Corrective Action Plan: Lawrence Williams, Chief Executive Officer. Corrective Action Plan: The Chief Executive Officer and Chief Financial Officer will ensure this important control procedure is rectified to...

Material Weakness 2022-001 Bank Statement Reconciliations Contact Person Responsible for Corrective Action Plan: Lawrence Williams, Chief Executive Officer. Corrective Action Plan: The Chief Executive Officer and Chief Financial Officer will ensure this important control procedure is rectified to ensure that bank reconciliations are performed and reviewed in a timely manner. Anticipated Completion Date of Corrective Action Plan: June 30, 2023

View Audit 19559

Finding 15916 (2022-002)

Material Weakness 2022

South Carolina State Housing Finance and Development Authority

SC

Questioned Costs Material Weakness Internal Control / Segregation of Duties

Housing Voucher Cluster ? Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements c...

Housing Voucher Cluster ? Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements controls to ensure abatement is timely for units that do not correct the cited HQS deficiencies within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Processes have been updated to assure that Yardi system generated letters are being utilized by staff for inspection deficiency correspondence. The vendor, Yardi, assumes responsibility for assuring that this correspondence meets all current regulatory requirements, as may be amended periodically. This will cure the notice deficiencies observed by the audit team. Additional training is being provided to HCP staff to insure they have a clear understanding of communication requirements and the critical timeline that accompanies the mitigation of exigent health and safety findings, other non-life threating deficiencies, as well as the follow-up inspection time frames allowed by HUD. Processes have been updated to require a monthly report of failed HQS inspections, to include all actions taken, be issued to the Director of Housing Choice Voucher and the Director of Rental Assistance and Compliance. This report is due by the first business day monthly and will be reviewed by senior management to determine abatements required and to issue authorization to abate within the HUD required timeframe. Memo records will be recorded on each voucher file to document actions taken. Financing Housing. Building SC. Names of the contact persons responsible for corrective action: Yolanda Dennison and Lisa Wilkerson Planned completion date for corrective action plan: Partially implemented; to be finalized by June 30, 2023.

View Audit 19599 Questioned Costs: $1

Finding 15915 (2022-001)

Material Weakness 2022

South Carolina State Housing Finance and Development Authority

SC

Material Weakness Internal Control / Segregation of Duties

Housing Voucher Cluster ? Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the Authority implement controls to ensure that required HQS and QC inspections are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actio...

Housing Voucher Cluster ? Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the Authority implement controls to ensure that required HQS and QC inspections are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Periodic HQS Inspections: Procedures are in place that require staff to generate a listing of all properties requiring inspection no less than one hundred twenty (120) days prior to the scheduled inspection date. Each unit under HAP contract must be inspected prior to execution of the initial lease and prior to execution of the HAP contract and no less than biennially thereafter to confirm the unit continues to meet minimum HUD requirements. Management identified a system generated report from YARDI to establish when recurring inspections must be completed. This report is generated a minimum of once monthly to assist with scheduling. The report is monitored by the Operations Manager and the Housing Choice Voucher Director. Procedures have been updated to require that the Director of Rental Assistance and Compliance review all inspections completed after the date due and the accompanying explanation for the delay. Management will track and analyze the data generated from the late inspections to identify patterns and implement corrective actions as warranted. Financing Housing. Building SC. QC Inspections: Upon discovery, a supervisor was assigned and all prior year HQS QC inspections were completed, albeit late. Effective April 1, 2023, and every month thereafter, the designated manager will conduct QC inspections utilizing the minimum file size sample based on the number of units under HAP contract annually. All required inspections will be completed no later than the end of each fiscal year. A status report documenting all efforts and results will be submitted monthly to the Director of Rental Assistance and Compliance. Management will track and analyze the data generated from these inspections to assure all program inspections are consistent and compliant and that any patterns identified are effectively addressed with additional training, etc. as warranted. Names of the contact persons responsible for corrective action: Lenzy Morris, Yolanda Dennison, Lisa Wilkerson Planned completion date for corrective action plan: June 30, 2023

View Audit 19599

Finding 15901 (2022-002)

Material Weakness 2022

Woodland School District No. 404

WA

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

Finding ref number: 2022-002 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: Stacy Brown, Director of Business Services 800 Second St Woodland, WA 98674-8467 (360) 8...

Finding ref number: 2022-002 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: Stacy Brown, Director of Business Services 800 Second St Woodland, WA 98674-8467 (360) 841-2715 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). The current vendor invoices do not break out when we are getting equipment and when there are staff onsite working. The work has been sporadic, so in the Business Office, we do not know when they are onsite and therefore not sure when payrolls are required. We are working with the maintenance department to keep us apprised when we have contractors onsite working on the HVAC (ESSER) projects. We originally thought we could get the weekly payrolls from the L&I website, but are finding that they are not posted timely and sometimes not at all. We are working directly with the vendors to provide weekly payrolls when they are working. The district has implemented a review log for all Federal projects requiring review of weekly payrolls. The Purchasing and Benefits Coordinator will document the vendor, week and certify that she has received and reviewed the payrolls received. Payment will be withheld if we do not receive the payrolls in a timely manner. Anticipated date to complete the corrective action: 6/12/23

View Audit 19549

Corrective Action Plans

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