Corrective Action Plans

Finding 559038 (2024-003)

Significant Deficiency 2024

AS

Student Financial Aid Reporting Significant Deficiency

Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or t...

Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has strengthened the review process by reinforcing the dual- review control system. In this system:  Control #1 (Financial Aid Coordinator) is responsible for conducting the initial review of the NSLDS Enrollment Report roster, performing data entry, and updating the status.  Control #2 (Financial Aid Manager) performs a secondary review and signs off on all NSLDS roster files before submission. Additionally, a log of all NSLDS submissions will be maintained, with both reviewers' signatures, to ensure proper documentation and accountability. Action Plan: The anticipated completion date for Finding Number 2024-0003 is March 2025

View Audit 355302

Finding 559027 (2024-003)

Significant Deficiency 2024

Manhattan Christian College

KS

Questioned Costs Reporting Internal Control / Segregation of Duties

The College is working to increase enrollment and adjusting the budget accordingly with available resources to reflect a positive net income from unrestricted operations.

View Audit 355294

Finding 559015 (2024-001)

Significant Deficiency 2024

Broome County Local Development Corporation

NY

Reporting

2024-001 Audit Adjustments Corrective Action Plan: Management will review transactions after year-end to ensure proper accounting and financial reporting. Additionally, the Agency has hired a new Financial Comptroller to oversee this process, with an anticipated start date at the end of March 2025...

2024-001 Audit Adjustments Corrective Action Plan: Management will review transactions after year-end to ensure proper accounting and financial reporting. Additionally, the Agency has hired a new Financial Comptroller to oversee this process, with an anticipated start date at the end of March 2025. Anticipated Completion Date: December 31, 2025. Contact Information Natalie Abbadessa, Director of Operations The Agency Broome County LDC 5 South College Drive Binghamton, New York 13905

View Audit 355268

Finding 559010 (2024-001)

Significant Deficiency 2024

Oglala Lakota College

SD

Reporting

Head Start Cluster 93.600 Significant Deficiency Internal Control over Reporting 2024-001 Condition: As of the January 2025 audit fieldwork date, the annual reports (Form SF 425) had not been filed for the years ended July 31, 2023 or July 31, 2024. Criteria: Instructions to Form SF-425, Feder...

Head Start Cluster 93.600 Significant Deficiency Internal Control over Reporting 2024-001 Condition: As of the January 2025 audit fieldwork date, the annual reports (Form SF 425) had not been filed for the years ended July 31, 2023 or July 31, 2024. Criteria: Instructions to Form SF-425, Federal Financial Report, require that quarterly and interim reports be submitted no later than 30 days after the reporting period and annual reports no later than 90 days after the reporting period. The reporting period ends July 31. Auditor’s Recommendation: We recommend that program directors provide information to the Federal Grant Manager timely to ensure reports are completed and submitted within established due dates. As noted, the July 31, 2023 and 2024 reports have since been filed and accepted by the federal agency. Management’s Response: Management will ensure that the Federal Grants Manager has access to all information necessary to submit reports for federal programs. As noted above, the reports were filed in March 2025 and have been accepted by the federal agency. If there are any questions regarding this plan, please contact Tanya Garnenez, Vice President of Business, at 605-455-6011. Respectfully, Tanya Garnenez, Vice President of Business Oglala Lakota College Kyle, South Dakota

View Audit 355250

Finding 559002 (2024-003)

None 2024

Town of Colchester, Ct

CT

Questioned Costs Reporting Internal Control / Segregation of Duties

The Town has reviewed the reporting procedures and how to maintain accurate expenditures, in accordance with U.S. Treasury guidelines. This corrective action has been sustained for the March 2025 filing, and will be adhered to for any subsequent reporting by the Director of Finance and the First S...

The Town has reviewed the reporting procedures and how to maintain accurate expenditures, in accordance with U.S. Treasury guidelines. This corrective action has been sustained for the March 2025 filing, and will be adhered to for any subsequent reporting by the Director of Finance and the First Selectman.

View Audit 355244

Finding 559000 (2024-001)

Material Weakness 2024

Allegheny County Industrial Development Authority

PA

Matching / Level of Effort / Earmarking Reporting § 200.303

Finding 2024-001: Reporting Management Response: The system to record IDA’s loan portfolio has an incorrect cash balance that has been carried forward from prior years. The cash balance is self populated within the reporting system which the Authority can’t correct. The Authority has...

Finding 2024-001: Reporting Management Response: The system to record IDA’s loan portfolio has an incorrect cash balance that has been carried forward from prior years. The cash balance is self populated within the reporting system which the Authority can’t correct. The Authority has reached out to our RLF portfolio manager at the EDA for guidance and resolution. Once corrected, we will have a separate finance team member review the reported cash balance agrees to IDA’s general ledger. Anticipated Completion Date: Immediate

View Audit 355242

Finding 558996 (2024-002)

Material Weakness 2024

Audubon Community School District

IA

Internal Control / Segregation of Duties Reporting

We will continue to review our control procedures to obtain the maximum internal controls possible under the circumstances.

View Audit 355241

Finding 558991 (2024-001)

Significant Deficiency 2024

Almost Home, Inc.

CO

Reporting § 200.510

Almost Home has begun establishing and finalizing a formal SEFA preparation schedule. Almost Home will also be retaining a CPA/Audit Consultant to work with the staff and conduct periodic reviews of the audit process and status.

View Audit 355240

Finding 558985 (2024-006)

Material Weakness 2024

Shelter and Assistance in Family Emergencies, Inc.

MS

Questioned Costs Internal Control / Segregation of Duties Cash Management

Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual wil...

Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual will be responsible for preparing reimbursement requests and subsequently submitting them; 4) provided extensive training to staff involved in the grant reimbursement procedures; 5) implemented a centralized grant tracking sheet to monitor billed amounts by category and date that is verified by two staff members; 6) implemented a quarterly internal audit review by a Board of Directors member with any findings reported to the Board of Directors for oversight.

View Audit 355230 Questioned Costs: $1

Finding 558984 (2024-002)

None 2024

Grandview Apartments, Inc.

PA

Questioned Costs HUD Housing Programs Reporting

Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management made a $11,400 deposit on 1/17/2025. The Project finally received the outstanding 2024 subsidy payments in February 2025 and Management made the additional deposit of $4,600 o...

Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management made a $11,400 deposit on 1/17/2025. The Project finally received the outstanding 2024 subsidy payments in February 2025 and Management made the additional deposit of $4,600 on 3/25/2025. The finding is cleared.

View Audit 355222 Questioned Costs: $1

Finding 558983 (2024-001)

None 2024

Grandview Apartments, Inc.

PA

Questioned Costs HUD Housing Programs Reporting

Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management submitted a Form 9250 Fund Authorization on March 26, 2025 for combined 2024 unapproved withdrawals and additional 2025 fund requests. Management is awaiting approval.

View Audit 355222 Questioned Costs: $1

Finding 558975 (2024-001)

Material Weakness 2024

City of Diamond Bar

CA

Subrecipient Monitoring Questioned Costs Material Weakness

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 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

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 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

Corrective Action Plans

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