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Finding 559732 (2024-001)
Material Weakness 2024
Central Valley School District No. 356
WA
Subrecipient Monitoring Internal Control / Segregation of Duties Procurement, Suspension & Debarment
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Central Valley School District No. 356 September 1, 2023 through August 31, 2024 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Central Valley School District No. 356 September 1, 2023 through August 31, 2024 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal wage rate requirements Name, address, and telephone of District contact person: Mathew Knott, Director of Business Services 2218 N. Molter Road Liberty Lake, WA 99019 509-558-5437 Corrective action the auditee plans to take in response to the finding: The district paid its final invoices toward these projects on October 10, 2023 for work that was performed through September 2023. While we realize there was a communication breakdown, and federal certified payroll reports were not collected, the District has put internal controls in place to ensure it complies with federal wage rate requirements. The District’s Purchasing Manager is responsible for creating all purchase orders related to capital projects, including those using federal funds. Prior to any purchase order being created the Purchasing Manager will ensure all required paperwork from the vendor is submitted and reviewed. That includes communication to the vendor on the district’s expectations around submitting weekly certified payroll reports. The Purchasing Manager will track and document this weekly during the life of the project. Anticipated date to complete the corrective action: 4/1/2025
View Audit 355620
Finding 559670 (2024-002)
Material Weakness 2024
Sioux Falls Regional Airport Authority
SD
Reporting Material Weakness § 200.303 § 200.327 § 200.328
Finding 2024-002 Department of Transportation Airport Improvement Program, CFDA #20.106 AIP3 46 0050 59, AIP3 46 0050 62, AIP3 46 0050 63, and AIP3 46 0050 64 Finding Summary: The SF-425 annual report dated September 30, 2024, for award AIP3 46 0050 64 underreported the federal share of expenditu...
Finding 2024-002 Department of Transportation Airport Improvement Program, CFDA #20.106 AIP3 46 0050 59, AIP3 46 0050 62, AIP3 46 0050 63, and AIP3 46 0050 64 Finding Summary: The SF-425 annual report dated September 30, 2024, for award AIP3 46 0050 64 underreported the federal share of expenditures by $23,588, while the FAA Form 5100-127 annual report dated December 31, 2023, for all awards underreported the total capital expenditures and construction in progress by $2,729,962. Responsible Individuals: Dan Letellier, Executive Director Corrective Action Plan: Management will ensure correct support documentation is provided to 3rd party account for correct submission of FAA Forms 5100-127. Director will also verify that annual report form SF-425 reconciles to underlying supporting records. Anticipated Completion Date: Ongoing
View Audit 355550
Finding 559669 (2024-003)
Material Weakness 2024
Central Iowa Regional Housing Authority
IA
HUD Housing Programs Subrecipient Monitoring Material Weakness
The Central Iowa Regional Housing Authority (CIRHA) agrees with the finding. The Executive Director (E.D.) will discuss details of the finding with the Fee Accountant and take any necessary steps. Monthly/annual financial reports and/or submissions will be reviewed at a more in depth level by the ...
The Central Iowa Regional Housing Authority (CIRHA) agrees with the finding. The Executive Director (E.D.) will discuss details of the finding with the Fee Accountant and take any necessary steps. Monthly/annual financial reports and/or submissions will be reviewed at a more in depth level by the E.D. The above corrective actions will be completed by May 15, 2025.
View Audit 355549
Finding 559668 (2024-002)
Material Weakness 2024
Central Iowa Regional Housing Authority
IA
Material Weakness Matching / Level of Effort / Earmarking
The Central Iowa Regional Housing Authority (CIRHA) agrees with the finding. CIRHA has corrected the material weakness/noncompliance by: reviewing Notice PIH 2023-014, discontinuing issuance of EHV’s when contacted by the EHV QAD Team in July 2024, re-issuing EHV’s issued in violation with HCV’s by...
The Central Iowa Regional Housing Authority (CIRHA) agrees with the finding. CIRHA has corrected the material weakness/noncompliance by: reviewing Notice PIH 2023-014, discontinuing issuance of EHV’s when contacted by the EHV QAD Team in July 2024, re-issuing EHV’s issued in violation with HCV’s by September 01, 2024; cooperating with the EHV QAD Team to determine/verify the amount of HAP received and Administrative Fees that were earned in error and payback procedure. The above corrective actions have been completed.
View Audit 355549
Finding 559258 (2024-001)
Material Weakness 2024
Kansas Hospital Association
KS
Subrecipient Monitoring Material Weakness Reporting
Identification: 93.889 United States Department of Health and Human Services, COVID-19 National Bioterrorism Hospital Preparedness Program, Noncompliance Finding/Material Weakness; Reporting Compliance Requirement. Corrective Action Plan: The Association will strengthen controls of federal grant rep...
Identification: 93.889 United States Department of Health and Human Services, COVID-19 National Bioterrorism Hospital Preparedness Program, Noncompliance Finding/Material Weakness; Reporting Compliance Requirement. Corrective Action Plan: The Association will strengthen controls of federal grant reporting for future awards so that any FFATA reporting requirements are completed in a timely manner. The Association will also modify the amount of the two subawards that were reported incorrectly in the Federal Funding Accountability and Transparency Act Subaward Reporting System. Anticipated completion date: The Association anticipates completion in 2025.
View Audit 355477
Finding 559153 (2024-005)
Material Weakness 2024
Catholic Charities Community Services, Inc. and Subsidiaries
AZ
Material Weakness Reporting Internal Control / Segregation of Duties
Item: 2024-005 Assistance Listing Number: 64.024 Program: VA Homeless Providers Grant and Per Diem Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is require...
Item: 2024-005 Assistance Listing Number: 64.024 Program: VA Homeless Providers Grant and Per Diem Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit per diem financial reports requesting payment based on the units of service provided multiplied by a per diem rate as specified in the grant agreement. Condition: In preparation of the per diem financial reports, the incorrect per diem rate was used to calculate the amount requested for payment for two reports. Name of Contact Person: Ana Pabon, Controller Phone Number: (602) 650-4852 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure updates to the per diem rates are identified timely. The Organization will also implement additional controls to ensure reports are reviewed and approved prior to submission to the granting agency. This review and approval will be clearly documented. The Organization also notes that this program has ended as of September 30, 2024.
View Audit 355383
Finding 559152 (2024-004)
Material Weakness 2024
Catholic Charities Community Services, Inc. and Subsidiaries
AZ
Cash Management Material Weakness Reporting
Item: 2024-004 Assistance Listing Number: 64.024 Program: VA Homeless Providers Grant and Per Diem Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is require...
Item: 2024-004 Assistance Listing Number: 64.024 Program: VA Homeless Providers Grant and Per Diem Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit monthly requests for reimbursement. Controls should be in place to ensure review and approval of these monthly reports prior to submission to the granting agency. Condition: Of the nine reports tested, there was no evidence of management review or approval for one of the reports prior to submission to the granting agency. Name of Contact Person: Ana Pabon, Controller Phone Number: (602) 650-4852 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure reports are reviewed and approved prior to submission to the granting agency. This review and approval will be clearly documented.
View Audit 355383
Finding 559150 (2024-003)
Material Weakness 2024
Catholic Charities Community Services, Inc. and Subsidiaries
AZ
Cash Management Material Weakness Reporting
Item: 2024-003 Assistance Listing Number: 64.033 Program: VA Supportive Services for Veteran Families Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is requir...
Item: 2024-003 Assistance Listing Number: 64.033 Program: VA Supportive Services for Veteran Families Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit monthly requests for reimbursement. Controls should be in place to ensure review and approval of these monthly reports prior to submission to the granting agency. Condition: For four reports tested, there was no evidence of management review or approval of the reports prior to submission to the granting agency. Name of Contact Person: Ana Pabon, Controller Phone Number: (602) 650-4852 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure reports are reviewed and approved prior to submission to the granting agency. This review and approval will be clearly documented.
View Audit 355383
Finding 559145 (2024-002)
Material Weakness 2024
Catholic Charities Community Services, Inc. and Subsidiaries
AZ
Cash Management Material Weakness Reporting
Item: 2024-002 Assistance Listing Number: 93.566 Program: Refugee and Entrant Assistance - State/Replacement Designee Administered Programs Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Arizona Department of Economic Security Compliance Requirement: Reporting C...
Item: 2024-002 Assistance Listing Number: 93.566 Program: Refugee and Entrant Assistance - State/Replacement Designee Administered Programs Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Arizona Department of Economic Security Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit monthly requests for reimbursement. Controls should be in place to ensure review and approval of these monthly reports prior to submission to the granting agency. Condition: For seven reports tested, there was no evidence of management review or approval of the reports prior to submission to the granting agency. Name of Contact Person: Ana Pabon, Controller Phone Number: (602) 650-4852 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure reports are reviewed and approved prior to submission to the granting agency. This review and approval will be clearly documented.
View Audit 355383
Finding 559087 (2024-009)
Material Weakness 2024
County of Ventura
CA
Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.510
Finding 2024-009 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...
Finding 2024-009 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC-06-0507, 95-6000807 Year: 2024 Compliance Requirement: Other - Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) - Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control over Compliance Department’s Management Response: Management agrees with the recommendation that the County enhance internal controls to ensure payments to subrecipients are appropriately reported on the SEFA. View of Responsible Officials and Corrective Action: To ensure compliance with §200.510(b) of the Uniform Guidance, the Auditor-Controller’s Office will provide additional detailed instructions when requesting departmental information for the County’s SEFA including obtaining expenditure details to support costs reported for subrecipients. In addition, a countywide training session will be conducted to assist departments in accurately completing the request. Name of Responsible Persons: Jason McGuire, Deputy Director, Auditor-Controller Implementation Date: August 2025
View Audit 355375
Finding 559086 (2024-008)
Material Weakness 2024
County of Ventura
CA
Subrecipient Monitoring Reporting Material Weakness § 200.303
Finding 2024-008 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...
Finding 2024-008 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC-06-0507, 95-6000807 Year: 2024 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Department’s Management Response: The County Executive Office’s Community Development Management agrees with the recommendation that the County implements internal controls to ensure subaward information is reviewed by management and submitted timely in accordance with the FFATA. View of Responsible Officials and Corrective Action: The County’s CDBG Policies and Procedures Manual was revised in April 2025 to address the review and timely submission of reports to ensure compliance with program requirements. CDBG program reports shall be reviewed by an independent staff member prior to submission, and documentation of this review and timely submission shall be maintained in the program’s official files. Name of Responsible Persons: Mary Ann Guariento, CDBG Program Management Analyst Kimberlee Albers, Deputy Executive Officer Implementation Date: April 7, 2025
View Audit 355375
Finding 559078 (2024-001)
Material Weakness 2024
Montpelier Housing Authority
VT
HUD Housing Programs Material Weakness Internal Control / Segregation of Duties § 200.514
RE: Audit Finding-Missing EIV Reports Montpelier Housing Authority Audit Finding Response: The auditor reviewed the finding with me and the following action plan was put in place to ensure that key EIV reports are run on a scheduled basis and appropriate actions are taken: • Policies and procedures ...
RE: Audit Finding-Missing EIV Reports Montpelier Housing Authority Audit Finding Response: The auditor reviewed the finding with me and the following action plan was put in place to ensure that key EIV reports are run on a scheduled basis and appropriate actions are taken: • Policies and procedures surrounding EIV were reviewed. •We implemented the use of a chart to prompt EIV reports within 90 days for new moveins. (see attached chart) •We already monitor EIV monthly and quarterly to ensure that EIV reports are run for all move-ins and re-certifications. This action plan is effective immediately, as of the date of this letter, February 17,2025.
View Audit 355365
Finding 559034 (2024-002)
Material Weakness 2024
Santa Monica Christian Towers, Inc. Hud Project No. 122sh088
CA
Questioned Costs Special Tests & Provisions HUD Housing Programs
The Managing Agent has requested and received authorization from HUD for the expenditure of funds from the Operating Account related to the design and planning of the Seismic Retrofit. The Managing Agent restored the funds expended from the Replacement Reserve Account from the Operating Account in F...
The Managing Agent has requested and received authorization from HUD for the expenditure of funds from the Operating Account related to the design and planning of the Seismic Retrofit. The Managing Agent restored the funds expended from the Replacement Reserve Account from the Operating Account in February 2025, subsequent to year-end. Management changes (including a revision of leadership) as well as a better understanding of HUD requirements will ensure this error does not happen again.
View Audit 355300 Questioned Costs: $1
Finding 558975 (2024-001)
Material Weakness 2024
City of Diamond Bar
CA
Subrecipient Monitoring Material Weakness Reporting
Corrective Action: The City acknowledges the finding regarding noncompliance with the continuing loan monitoring requirements for the Community Development Block Grant (CDBG) Home Improvement Program. We recognize the importance of ensuring full compliance with all grant requirements to maintain the...
Corrective Action: The City acknowledges the finding regarding noncompliance with the continuing loan monitoring requirements for the Community Development Block Grant (CDBG) Home Improvement Program. We recognize the importance of ensuring full compliance with all grant requirements to maintain the integrity and effectiveness of the program. Training and Awareness: The City will provide comprehensive training to all relevant staff/consultants on the continuing loan monitoring requirements outlined in the LACDA grant agreement and CDBG program guidelines. Training sessions will be completed by June 30, 2026. Policy and Procedure Updates: The City will review and update its internal policies and procedures to clearly document the continuing loan monitoring process. A standardized compliance checklist and loan monitoring schedule will be developed to ensure consistent implementation across all loans. Loan Monitoring and Documentation: By June 30, 2026 the City will implement a regular schedule for evaluating outstanding loans, including, borrower compliance reviews, and follow-up actions where necessary. All monitoring activities will be fully documented and retained in each loan file. Ongoing Oversight: Management will assign a designated staff member/consultant responsible for overseeing the continuing loan compliance process, ensuring ongoing adherence to program requirements and addressing any issues promptly. The City is committed to strengthening internal controls, ensuring compliance with grant requirements, and maintaining the credibility of the Home Improvement Program. Proposed Completion Date: The corrective actions outlined above will be fully implemented by June 30, 2026.
View Audit 355203
Finding 558862 (2024-065)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions
Finding: The Community Colleges of Spokane did not have adequate controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: The College District will...
Finding: The Community Colleges of Spokane did not have adequate controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: The College District will enhance our monthly financial reporting to include a unique identifier for monthly expenditures. Additionally, a report of expenditures procured by credit card will be attached to the regular financial report. The College District acknowledges the importance of clear documentation and tracking of the required training and meeting attendance by all Board of Trustees members and Policy Council members. Beginning in March 2025, the College District started providing additional methods and opportunities for new members to receive fiscal and governance training. To strengthen controls over program governance requirements and to demonstrate the commitment to continuous improvement of existing processes, the College District will further document training completion and the distribution of monthly financial information to all members. Completion Date: Estimated June 2025 Agency Contact: Linda McDermott Chief Financial Officer 501 N Riverpoint Blvd, PO Box 6000 Spokane, WA 99217-6000 (509) 434-5275 Linda.McDermott@ccs.spokane.edu
View Audit 355165
Finding 558861 (2024-064)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions
Finding: Skagit Valley College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: The College has rev...
Finding: Skagit Valley College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: The College has reviewed and strengthened current internal controls to ensure the Board receives the required financial and credit card statements monthly and that all new Board members receive training within the required 180 days. Financial reporting procedures The Head Start Program Director prepares monthly reporting to be available for inclusion in the monthly board packet, or as requested. In January 2025, the Procedures of Policy Council and Board Reporting were updated to ensure that required monthly reporting is provided to each governing body, regardless of whether there is a scheduled meeting for that month. This procedure became effective for the February 2025 Board of Trustees meeting. All financial reporting that was not previously provided to the Board of Trustees for the period covering July 1, 2023, through December 31, 2024, was transmitted on February 24, 2025. Board member training In January 2025, the Head Start Director provided the Board of Trustees an updated document on the program’s selection criteria and enrollment process. Additionally, the Head Start Board of Trustees Handbook, which has incorporated other training materials, was provided to each board member. The Head Start Director will conduct an annual review of the handbook content and update as appropriate to ensure training materials remain current. Completion Date: March 2025 Agency Contact: Mike Cogan VP of Administrative Services and CFO 2405 East College Way Mount Vernon, WA 98273-5899 (360) 899-2945 mike.cogan@skagit.edu
View Audit 355165
Finding 558860 (2024-063)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility
Finding: Edmonds College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: In response to the audit finding, ...
Finding: Edmonds College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: In response to the audit finding, the College will explore options for a Governing Body that complies with governance requirements for the Head Start program. By May 2025, the College will consult with its Assistant Attorney General to discuss the composition of a new Governing Body and will take the necessary steps to fully comply with federal regulations. By July 2025, the College will: • Establish a Governing Body that is compliant with requirements outlined in the Head Start Act to perform the required monthly review of financial and credit card statements, major financial expenditures, and any funding applications. • Ensure the Policy Council receives and approves the required financial and credit card statements each month. • Provide training to the new Governing Body and active members of the Policy Council within the required 180 days. Completion Date: Estimated July 2025 Agency Contact: Ginger Williams Head Start Executive Director 20816 44th Ave. W. Lynnwood, WA 98036-7744 (425) 550-3840 ginger.williams@edmonds.edu
View Audit 355165
Finding 558859 (2024-062)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties
Finding: Edmonds College did not have adequate internal controls over and did not comply with protection of federal interest requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response ...
Finding: Edmonds College did not have adequate internal controls over and did not comply with protection of federal interest requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response to the audit finding, Edmonds College has completed the following: • Established a written protocol with the Department of Enterprise Services (DES) to ensure the Head Start Program Performance Standards 1303.46 is met in recording and posting federal interest. • Established internal controls to ensure college management monitor future work with DES to properly complete the Office of Head Start Lease Rider attachment in the lease agreements where federal funds are used to renovate leased property. Completion Date: February 2025 Agency Contact: Ginger Williams Head Start Executive Director 20816 44th Ave. W. Lynnwood, WA 98036-7744 (425) 550-3840 ginger.williams@edmonds.edu
View Audit 355165
Finding 558785 (2024-081)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Material Weakness Reporting
Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it performed procedures to safeguard against unnecessary utilization of care and services for the Medicaid program. Questioned Costs: Assistance Listing # 93.775 93.7...
Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it performed procedures to safeguard against unnecessary utilization of care and services for the Medicaid program. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action in progress Corrective Action: The Authority concurs with the finding and continues to develop and implement its statewide surveillance and utilization control program by: • Updating its Surveillance Utilization Review Subsystem policies and procedures. • Updating and documenting its statewide monitoring program. • Documenting its internal control program to ensure it complies with all utilization control requirements. The conditions noted in this finding were previously reported in findings 2023-082, 2022-061, 2021-050, 2020-047, 2020-048, 2019-052, 2019-053, and 2018-047. In fiscal year 2024, the State Auditor’s Office determined the Authority resolved findings 2020-047, 2020-048, 2019-052, 2019-053, and 2018-047. Completion Date: Estimated June 2026 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 42724 Olympia, WA 98504-2691 (360) 725-9586 Kari.Summerour@hca.wa.gov
View Audit 355165
Finding 558784 (2024-080)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Special Tests & Provisions Material Weakness
Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it periodically audited cost report data for rate setting, hospital billings, and other financial and statistical records for inpatient hospital services. Questioned Cos...
Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it periodically audited cost report data for rate setting, hospital billings, and other financial and statistical records for inpatient hospital services. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action not taken Corrective Action: The Authority does not concur with the finding. The Authority maintains its internal controls are effective, and policies and procedures are compliant with federal requirements. Over the past four years, the Authority has taken corrective action on the prior audit findings including: • Consulted with the Centers for Medicare & Medicaid Services (CMS) for direction. • Updated Washington Administrative Code and the Revised Code of Washington to align with federal regulations. • Provided for the filing of cost reports and audited or contracted for the audit of the financial and statistical records of inpatient hospitals. CMS provided the Authority with technical guidance on two occasions, indicating it defers to the states on how these audits are defined. The Authority believes it has addressed the deficiencies identified in previous audits and no additional corrective action will be taken. The conditions noted in this finding were previously reported in findings 2023-081, 2022-060, 2021-051, and 2020-049. Completion Date: Not applicable Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 42724 Olympia, WA 98504-2691 (360) 725-9586 Kari.summerour@hca.wa.gov
View Audit 355165
Finding 558783 (2024-079)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions
Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 9...
Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration did not have adequate internal controls over and did not comply with survey requirements for Medicaid nursing homes. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially concurs with the finding. The Department was not able to meet the Nursing Home Recertification Survey requirements due to a backlog from prior years, not because of lack of internal controls. It was through applied internal controls that we identified concerns and were able to allocate resources to meet the most serious concerns. The Department made efforts in fiscal year 2023 and 2024 to address the backlog of complaints and recertification surveys, but resources had to be prioritized for new complaints. There is only one team that manages surveys, complaints, and revisits for the entire state. To optimize the use of resources, the Field Manager meets with the Administrative Assistant on a quarterly basis to review the 365-day average report and determine if survey schedules need to be modified to meet federal requirements To continue to address this audit issue, regional administrators have met with their Nursing Home teams to review survey scheduling for the year to ensure teams will be able to meet targeted survey completion dates and the required survey and recertification timeframes. By January 2026, the Department expects to meet compliance with the 15.9-month recertification survey timeline and the 12.9-month statewide average. The conditions noted in this finding were previously reported in findings 2023-079 and 2020-054. Completion Date: Estimated January 2026 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
View Audit 355165
Finding 558782 (2024-078)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles
Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid intermediate care facilities. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 C...
Finding: The Department of Social and Health Services, Aging and Long-Term Support Administration, did not have adequate internal controls over and did not comply with survey requirements for Medicaid intermediate care facilities. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially concurs with the finding. The Department was not able to meet the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) survey requirements due to a backlog from prior years, not because of lack of internal controls. It was through applied internal controls that we identified concerns and were able to allocate resources to meet the most serious concerns. The Department made efforts in fiscal year 2023 and 2024 to address the backlog of complaints and recertification surveys, but resources had to be prioritized to handle new complaints. There is only one team that manages surveys, complaints, and revisits for the entire state. To optimize the use of resources, the Field Manager meets with the Administrative Assistant on a quarterly basis to review the 365-day average report and determine if survey schedules need to be modified to meet federal requirements. To continue to address this audit issue, regional administrators have met with their ICF/IID teams to review survey scheduling for the year to ensure teams will be able to meet targeted survey completion dates and the required recertification timeframes. By January 2026, the Department expects to meet compliance with the 15.9-month recertification survey timeline and the 12.9-month statewide average. The conditions noted in this finding were previously reported in findings 2023-078, 2020-053, 2019-061, 2018-052, 2017-042, 2016-037, 2015-045, and 2014-046. Completion Date: Estimated January 2026 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
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Finding 558781 (2024-077)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking
Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it referred all credible allegations of provider fraud to the state’s Medicaid Fraud Control Unit. Questioned Costs: Assistance Listing # 93.775 9...
Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it referred all credible allegations of provider fraud to the state’s Medicaid Fraud Control Unit. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department and its contractor, Consumer Direct Care Network Washington (CDWA), identify potential and suspected provider fraud and refer fraud allegations with a potential loss of $1,000 or more to the Medicaid Fraud Control Unit (MFCU). Fraud referrals under $1,000 are all reviewed and tracked to enable repeat referrals to be identified and compiled to show a pattern of possible fraudulent behaviors. For cases under $1,000, CDWA completes provider education and training on billing standards, which will be documented and used to support any future referrals. The 15 cases identified in the audit finding that were not referred to MFCU were each under $1,000 of potential loss. Provider education was completed by CDWA, and the funds were returned to Medicaid. As of February 2025, the Department met with CDWA to discuss a revised process that will ensure compliance with MFCU requirements. In addition, the Medicaid Provider Fraud Referral form DSHS 12-210 was modified to include CDWA as an entity. By May 2025, the Department and CDWA will: • Revise and finalize existing procedures related to the referrals of all credible allegations of fraud to MFCU regardless of the amount of potential loss. • Request approval for the creation of a ticketing system for CDWA to submit provider fraud referrals directly into SharePoint. This will streamline the process, reduce workload, and help ensure compliance with MFCU requirements. Completion Date: Estimated May 2025 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
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Finding 558780 (2024-076)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Internal Control / Segregation of Duties Subrecipient Monitoring Special Tests & Provisions
Finding: The Department of Health did not have adequate internal controls over and did not comply with requirements to ensure timely review of hospital complaints. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action complete ...
Finding: The Department of Health did not have adequate internal controls over and did not comply with requirements to ensure timely review of hospital complaints. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action complete Corrective Action: The Department has a process in place to screen complaints for possible imminent danger. The Department has assessed and strengthened internal controls within the licensing and regulatory systems that are necessary to demonstrate compliance. The systems will properly reflect the accurate date of initial screening for imminent danger within two working days of receiving a complaint, as required by the Centers for Medicare and Medicaid Services State Operations Manual, and subsequent 21-day basic assessment and review timeline per internal policies. Additionally, the Department is performing quarterly audits to confirm and document that timely screening of complaints is taking place as required. The conditions noted in this finding were previously reported in finding 2023-076. Completion Date: August 2024 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov
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Finding 558727 (2024-029)
Significant Deficiency 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Material Weakness Reporting
Finding: The Department of Social and Health Services did not have adequate internal controls to ensure it filed reports timely as required by the Federal Funding Accountability and Transparency Act. Questioned Costs: Assistance Listing # 93.044 93.044 COVID-19 93.045 93.045 COVID-19 93.053 ...
Finding: The Department of Social and Health Services did not have adequate internal controls to ensure it filed reports timely as required by the Federal Funding Accountability and Transparency Act. Questioned Costs: Assistance Listing # 93.044 93.044 COVID-19 93.045 93.045 COVID-19 93.053 Amount $0 Status: Corrective action complete Corrective Action: The Department concurs with the finding. As of January 2024, the Department: • Created a subawards and amendments tracking spreadsheet with the required fields and contract information for reports required by the Federal Funding Accountability and Transparency Act (FFATA). • Assigned two fiscal staff to ensure FFATA reporting activities are submitted in the Federal Funding Accountability and Transparency Subaward Reporting System (FSRS). As of February 2024, the Department: • Ensured federal fiscal year 2024 funded contracts that were executed in December 2023 for the Office of Aging were entered in FSRS. • Added procedures for the Office Chief or designee to review the subawards and amendments tracking spreadsheet monthly for FFATA reporting to ensure federal deadlines are met consistently. As of March 2024, the Department collaborated with the Administration of Community Living and developed a plan to address the FFATA reporting backlog in state fiscal years 2022 and 2023 and ensured all FFATA reports were entered in FSRS for all previous years. The conditions noted in this finding were previously reported in finding 2023-039. Completion Date: March 2024 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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