Corrective Action Plans

Finding 558971 (2024-006)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Student Financial Aid Special Tests & Provisions Eligibility

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system ...

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system (Banner from Ellucian). All students who have withdrawn are being updated through National Student Clearinghouse and from there to NSLDS.

View Audit 355176

Finding 558941 (2024-002)

Significant Deficiency 2024

Fisk University

TN

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financ...

Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financial reporting and audit preparation processes. Items that can be compiled prior to year-end will be identified and the compilation of those items will begin. Areas that presented challenges during the FY 24 audit will be given special attention in advance. Lastly, audit assignments will be delegated to improve response efficiency. A detailed closing schedule has been developed. Staff duties and responsibilities have been reassigned and repurposed to improve processing timelines and audit preparation. The audit timeline will be monitored more closely to ensure timely responses to audit requests that support the timely completion and issuance of the audit to meet Uniform Guidance timeline requirements.

View Audit 355168

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 558858 (2024-061)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties

Finding: Edmonds College did not have adequate controls over reporting 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, the College established a documented procedu...

Finding: Edmonds College did not have adequate controls over reporting 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, the College established a documented procedure for the compilation and submission of the SF-425 reports to ensure compliance with federal requirements. This procedure includes: • Defining roles and responsibilities of staff. • Performing a secondary review of all reports before submission. • Retaining source data used in creating the reports. Completion Date: April 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

View Audit 355165

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

View Audit 355165

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

View Audit 355165

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

View Audit 355165

Finding 558697 (2024-083)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Reporting

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it filed accurate and timely reports required by the Federal Funding Accountability and Transparency Act for the Block Grants for Substance Use Prevention, Treatment, and R...

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it filed accurate and timely reports required by the Federal Funding Accountability and Transparency Act for the Block Grants for Substance Use Prevention, Treatment, and Recovery Services. Questioned Costs: Assistance Listing # 93.959 93.959 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Authority implemented a new process to identify and report contracts required to be reported by the Federal Funding Accountability and Transparency Act in early fiscal year 2024. A reconciliation process to ensure all reports are filed as required was then developed and implemented in April 2024. After implementation, several inconsistencies were identified and resolved in June and July 2024. Updated training was provided to staff involved in the process to resolve the identified issues. The conditions noted in this finding were previously reported in findings 2023-086, 2022-069, and 2021-058. Completion Date: July 2024 Agency Contact: William Sogge, CPA, CIA External Audit Compliance Specialist PO Box 42724 Olympia, WA 98504-2691 (360) 725-5110 william.sogge@hca.wa.gov

View Audit 355165

Finding 558696 (2024-082)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Questioned Costs Reporting Subrecipient Monitoring

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure payments to providers for the Block Grants for Substance Use Prevention, Treatment, and Recovery Services program were allowable and met period of performance requirements....

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure payments to providers for the Block Grants for Substance Use Prevention, Treatment, and Recovery Services program were allowable and met period of performance requirements. Questioned Costs: Assistance Listing # 93.959 93.959 COVID-19 Amount $10,467,736 Status: Corrective action not taken Corrective Action: The Authority does not concur with the finding. The Authority maintains that its internal controls are effective, and procedures are compliant with grant requirements. No corrective action will be implemented. The costs questioned by the auditor do not reflect funds that have been paid or drawn from the grantor. As a result, there are no funds to return to the grantor. The conditions noted in this finding were previously reported in findings 2023-084 and 2022-067. Completion Date: Not applicable Agency Contact: William Sogge, CPA, CIA External Audit Compliance Specialist PO Box 42724 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov

View Audit 355165 Questioned Costs: $1

Finding 558689 (2024-075)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid and Children’s Health Insurance Program. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 93.775 93.777 93.777 COVID...

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid and Children’s Health Insurance Program. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $3,844,961 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority does not concur with the auditor’s assertion that two providers did not have a valid Core Provider Agreement on file. The Authority also does not concur that two new providers were enrolled without completion of a full enrollment screening. Corrective action has been in process to address revalidation issues from prior audits. As of January 1, 2024, the Authority implemented a system change moving the revalidation date to 90 days before the end of the five-year period. The Authority is revising existing procedures to strengthen internal controls over provider enrollment. Additional procedure implementation is also in progress to ensure high risk providers receive fingerprint-based background checks. Regarding the nursing facility revalidations, the Authority operates cooperatively under a written agreement with the Department of Social and Health Services (Department) who carry out the nursing facility licensing and revalidations. The Department stated: Effective May 2024, the Department updated the nursing facility revalidation process to require the Facilities Contract Specialist review the nursing facility revalidation monitoring spreadsheet monthly and that revalidation paperwork will be sent one year before the due date to ensure revalidation is done ahead of the 5-year period. In addition, the Department will consult with the Authority to determine if it is feasible to automate the revalidation notices. By December 31, 2025, Department contracts staff will verify that the Medicaid Provider Disclosure Statement forms are in the Management Operation Document Imaging System for all nursing facilities and that each form has been completed within the 5-year period. The conditions noted in this finding were previously reported in findings 2023-074, 2022-055, 2021-047, 2020-046, 2019-048, 2018-042, 2017-033, and 2016-035. Completion Date: Estimated December 2025 Agency Contact: William Sogge External Audit Compliance Specialist PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov

View Audit 355165 Questioned Costs: $1

Finding 558688 (2024-074)

Material Weakness 2024

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: Audited financial reports: The Authority amended the managed care contract to require Managed Care Organizations to submit financial statements prepared in accordance with Generally Accepted Accounting Principles and Generally Accepted Auditing Standards. The amended contract requirement went into effect January 1, 2025. Periodic audits: The Authority implemented internal controls during state fiscal year 2024 to ensure periodic audits are completed within the required timeline. The conditions noted in this finding were previously reported in findings 2023-073, 2022-054, and 2021-048. Completion Date: June 2024 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 558685 (2024-073)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Reporting

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with reporting requirements to ensure reports were complete and accurate for the Social Services Block Grant program. Questioned Costs: Assistance Listing # 93.667 Status...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with reporting requirements to ensure reports were complete and accurate for the Social Services Block Grant program. Questioned Costs: Assistance Listing # 93.667 Status: Corrective action in progress Corrective Action: Completion Date: The Department maintains that funds were not improperly charged or reported for the Social Services Block Grant (SSBG) program. The Department provided the State Auditor’s Office (SAO) with detailed expenditure data reports, email documentation showing management’s review of the expenditures being charged to the SSBG program and changes being requested prior to federal submission. In addition, the federal reporting system creates an email after certification, which the Department shared with the SAO. The Department implemented grant-level management of all federal funds, including the SSBG program. This process consists of making grant-level adjustments between allowable grant sources to properly spend grant funds within the allowable period of performance and ensure level of effort and matching requirements are met. The Department allocated the SSBG funds to eligible clients and allowable activities in compliance with 45 CFR 98.67 but did not include the level of data recommended by the SAO for some transfers. In response to the auditor’s recommendations, the Department submitted a budget request for the 2024 supplemental budget. The enacted budget included funding to implement the Department’s budget request beginning July 1, 2024. The Department is working with a developer to assist with building out the required databases between the Social Service Payment System and the Agency Financial Reporting System to allow transfers between funding sources to include transaction level data related to the expenditures. The Department is committed to collaborating with SAO to determine an appropriate methodology which identifies a sampling unit that can be used to accurately test compliance. The Department looks forward to working with SAO to resolve the data concerns in the audit of the SSBG program. The conditions noted in this finding were previously reported in finding 2023-072. Estimated December 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165

Finding 558665 (2024-071)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure Foster Care Maintenance payment rates were properly calculated. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective ...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure Foster Care Maintenance payment rates were properly calculated. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action in progress Corrective Action: The Department concurs that policies and procedures related to rate setting for Foster Care maintenance payments are not currently established and is committed to strengthening internal controls and complying with federal requirements. In February 2025, the Department met with the State Auditor’s Office to gather an understanding of concerns and discuss how reasonable and allowable rates could be documented to ensure federal compliance. The Department will prioritize establishing written policies and procedures for setting payment rates to ensure maintenance payment rates only include allowable costs. Completion Date: Estimated July 2026 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

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Finding 558664 (2024-070)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Reporting Subrecipient Monitoring Material Weakness

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 Status: Corrective action complete Corrective Act...

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 Status: Corrective action complete Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. As stated in the finding’s Cause of Condition, the Department did not follow the U.S. Department of Health and Human Services’ (HHS) published instructions. To address the auditor’s specific recommendations, the Department has: • Reviewed and updated all electronic versions of the quarterly crosswalks to align with HHS instructions. • Submitted a correction to the April 2025 quarterly report. The conditions noted in this finding were previously reported in findings 2023-069 and 2022-051. Completion Date: April 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

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Finding 558663 (2024-069)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Eligibility

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure a child is eligible and group care facility employees and adults residing in prospective caregivers’ households had cleared background checks before having unsupervised access to children. Q...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure a child is eligible and group care facility employees and adults residing in prospective caregivers’ households had cleared background checks before having unsupervised access to children. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. For the specific exceptions identified in the finding, the Department has taken the following actions: Individuals: • Updated the source of funds in the FamLink application for the child identified in the audit exception to ensure future payments would be made with state funds. • Researched all payments made on behalf of the child and returned the federal portion to the grantor. • Updated the peer review process to ensure that a sample of cases are reviewed quarterly and all documentation is properly retained. Background Checks: • In January 2024, the Department increased its use of National Crime Information Center (NCIC) background checks to ensure all individuals required to complete fingerprint-based checks are compliant prior to a child’s placement. • The Department continues to use the Plan, Do, Check, Act (continuous quality improvement process) to communicate changes and provide additional training to staff as needed to ensure compliance with the background check requirement. The conditions noted in this finding were previously reported in findings 2023-068 and 2022-050. Completion Date: January 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165 Questioned Costs: $1

Finding 558661 (2024-067)

Significant Deficiency 2024

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 monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Sta...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. As stated in the finding’s Cause of Condition, the Department did not fully implement the prior year’s corrective action plan during the audit period and did not have the reporting capabilities to track rate setting reviews for the entire audit period. To strengthen internal controls and documentation, and as part of the implementation of the new rate assessment process, the Department took the following corrective actions: • Published a new report in FamLink to assist rate assessors in identifying: o Six-month reviews that have not been performed timely. o Cases with upcoming rate assessments and due dates for reviews. • Implemented monthly tracking by supervisors to assist with internal controls and compliance. The Department continues to use the Plan, Do, Check, Act (continuous quality improvement process) to improve the accuracy of the new reports and provide additional training to staff as needed to ensure compliance with the requirement of performing six-month reviews of the reimbursement rates. The conditions noted in this finding were previously reported in finding 2023-067. Completion Date: June 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

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Finding 558660 (2024-066)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

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 Statu...

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 prior year audit finding, the Department has taken the following actions: • Between April and December 2023: o Filled two vacant contract staff positions dedicated to reviewing child welfare contracts to include family time visit payments. o Developed compliance audit plans for child welfare contracts and began fiscal monitoring of family time visit payments. o Implemented a new process for creating Sprout invoices from family time activity data to include the following:  Utilizing algorithms to identify reimbursements outside of reasonable amounts.  Requiring providers to submit additional documentation or explanation for flagged invoices.  Identifying duplicate billings using a re-run process.  Performing additional review and approval of invoices of the Network Administrator in Eastern Washington prior to release of payment. • Between January and March 2024: o Identified and implemented regional program approvals for Western Washington providers. o Implemented fiscal monitoring controls to ensure payments to providers for travel and family visits are allowable and adequately supported. o Utilized the Plan, Do, Check, Act (continuous quality improvement process) to add additional steps to the process to ensure payments were accurate. In response to the State Auditor’s Office (SAO) recommendations, the Department will: • Reconcile the identified payment exceptions and take appropriate action. • Review the implemented invoice and payment process and update training resources as needed. • Refine the compliance audit plans and update documentation for the contract monitoring process to ensure that SAO can review documentation for monitoring tasks completed. The conditions noted in this finding were previously reported in findings 2023-066, 2022-048, and 2021-040. Completion Date: Estimated July 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165 Questioned Costs: $1

Finding 558650 (2024-053)

Material Weakness 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Reporting

Finding: The Department of Commerce did not have adequate internal controls over and did not comply with reporting requirements for the Low-Income Home Energy Assistance Program. Questioned Costs: Assistance Listing # 93.568 93.568 COVID-19 Amount $0 Status: Corrective action in progress ...

Finding: The Department of Commerce did not have adequate internal controls over and did not comply with reporting requirements for the Low-Income Home Energy Assistance Program. Questioned Costs: Assistance Listing # 93.568 93.568 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Low-Income Home Energy Assistance Program (LIHEAP) staff will work with the Financial Services Division staff to enhance and improve internal controls and ensure accurate reporting which will include the following: • Budget staff will review and approve the SF-425 federal financial reports, the Carryover and Reallotment Report, and the Grantee Survey Section 1 for completeness and accuracy prior to submission to the program for entry into the federal reporting system. • Budget and accounting staff will ensure Module 1 of the LIHEAP Performance Data Form reconciles to the amounts reported on both the Carryover and Reallotment and the SF-425 reports to prevent reporting inconsistencies. • LIHEAP Energy and Weatherization staff will coordinate activities between their programs to include: o Completing a memorandum of understanding outlining reporting requirements and timelines. o Scheduling time to attend training on reporting timelines and data accuracy requirements. o Tracking data on weatherization obligations, households served, and expenditures for required federal reporting. The Department’s information technology (IT) staff completed system updates to correct identified issues and ensure alignment with the federal reporting guidelines. IT staff will continue to monitor and refine data processes to improve accuracy and consistency. The conditions noted in this finding were previously reported in findings 2023-055, 2022-039, and 2021-032. Completion Date: Estimated August 2025 Agency Contact: Gena Allen, CFE Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov

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Corrective Action Plans

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