Corrective Action Plans

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CORRECTIVE ACTION PLAN Breakthrough Phase III, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from...
CORRECTIVE ACTION PLAN Breakthrough Phase III, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS — FINANCIAL STATEMENT AUDIT None FINDINGS — FEDERAL AWARD PROGRAMS AUDITS FINDING NO. 2023-001: Late REAC submission for Section 811 Supportive Housing for Persons with Disabilities, ALN #14.181 Criteria: The Project is required to submit audited financial statements with the REAC system within 90 days after year end. Cause of Condition: The Project did not have systems in place to submit the audited financial statements within the required 90 days. Recommendation: Auditor recommends management implement systems to ensure audited financial statements are submitted to REAC as required by the U.S. Department of Housing and Urban Development within 90 days after the fiscal year end. Action Taken: Personnel at Breakthrough Corporation have contracted with an outside accounting firm to handle the bookkeeping and will ensure that the year end financial reports will be provided to necessary third parties as soon as possible after the end of the fiscal year.
CORRECTIVE ACTION PLAN Breakthrough Phase II, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from...
CORRECTIVE ACTION PLAN Breakthrough Phase II, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS — FINANCIAL STATEMENT AUDIT None FINDINGS — FEDERAL AWARD PROGRAMS AUDITS FINDING NO. 2023-001: Late REAC submission for Section 811 Supportive Housing for Persons with Disabilities, ALN #14.181 Criteria: The Project is required to submit audited financial statements with the REAC system within 90 days after year end. Cause of Condition: The Project did not have systems in place to submit the audited financial statements within the required 90 days. Recommendation: Auditor recommends management implement systems to ensure audited financial statements are submitted to REAC as required by the U.S. Department of Housing and Urban Development within 90 days after the fiscal year end. Action Taken: Personnel at Breakthrough Corporation have contracted with an outside accounting firm to handle the bookkeeping and will ensure that the year end financial reports will be provided to necessary third parties as soon as possible after the end of the fiscal year.
CORRECTIVE ACTION PLAN Breakthrough Phase I, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from ...
CORRECTIVE ACTION PLAN Breakthrough Phase I, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS — FINANCIAL STATEMENT AUDIT None FINDINGS — FEDERAL AWARD PROGRAMS AUDITS FINDING NO. 2023-001: Late REAC submission for Section 811 Supportive Housing for Persons with Disabilities, ALN #14.181 Criteria: The Project is required to submit audited financial statements with the REAC system within 90 days after year end. Cause of Condition: The Project did not have systems in place to submit the audited financial statements within the required 90 days. Recommendation: Auditor recommends management implement systems to ensure audited financial statements are submitted to REAC as required by the US. Department of Housing and Urban Development within 90 days after the fiscal year end. Action Taken: Personnel at Breakthrough Corporation have contracted with an outside accounting firm to handle the bookkeeping and will ensure that the year end financial reports will be provided to necessary third parties as soon as possible after the end of the fiscal year.
Name of contact person and title: Tabatha Miller, Finance Director Anticipated completion date: May 15, 2024 Auditee’s response: Concur Planned Corrective Action: Management will file the audited financial statements for the year ended June 30, 2023, as soon as possible. The City developed procedure...
Name of contact person and title: Tabatha Miller, Finance Director Anticipated completion date: May 15, 2024 Auditee’s response: Concur Planned Corrective Action: Management will file the audited financial statements for the year ended June 30, 2023, as soon as possible. The City developed procedures, including a fiscal year-end closing schedule to assist in meeting the timeliness requirements of Section 200.512(a) of the Uniform Guidance. The City has identified the need for additional accounting staff hours to complete the procedures outlined in the fiscal year-end closing schedule.
Finding 397709 (2023-002)
Significant Deficiency 2023
Finding Reference Number: 2023-002 Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit Report to the federal clearinghouse in May 2024, 2 months after it was due. Statement of Concurrence or Nonconcurrence: Operation Care agrees with the find...
Finding Reference Number: 2023-002 Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit Report to the federal clearinghouse in May 2024, 2 months after it was due. Statement of Concurrence or Nonconcurrence: Operation Care agrees with the finding as stated above. Corrective Action: Operation Care will ensure that all future Audited Financial Statements and Single Audit Reports are submitted to the federal clearing house no later than March 31st of each year. If Operation Care is needing an extension, the Fiscal Director will work with the Auditors to ensure that an extension is filed so Operation Care will stay in compliance. The Fiscal Director will also cross train the Executive Director on SEFA updates and Audited Financial Statements to ensure if there is turnover in personnel, someone at Operation Care will be able to provide the proper documentation to the Auditors in a timely manner. Name of Contact Person: Ashley Carnicello, Executive Director, (209) 223-2897 ashley@operationcare.org Bruce Platt, Fiscal Director (209) 223-2897 bruce@operationcare.org Projected Completion Date: The Fiscal Director will cross train the Executive Director by the end of the Fiscal Year, June 30, 2024 to ensure timely submission of Audited Financial Statements and Single Audit Reports. In addition, the Fiscal Director and Executive Director will begin submitting requests for Auditors by September 30th of each year. This will allow Operation Care to begin the Audit process earlier, therefore making the March 31st deadline more feasible.
Finding 397708 (2023-001)
Significant Deficiency 2023
Finding Reference Number: 2023-001 Description of Finding: The schedule of Expenditures of Federal Awards (SEFA) was not complete, and expenditures reported on the SEFA were revised during the single audit. Statement of Concurrence or Nonconcurrence: Operation Care agrees with the finding a...
Finding Reference Number: 2023-001 Description of Finding: The schedule of Expenditures of Federal Awards (SEFA) was not complete, and expenditures reported on the SEFA were revised during the single audit. Statement of Concurrence or Nonconcurrence: Operation Care agrees with the finding as stated above. Corrective Action: Beginning immediately, Operation Care will keep a running, updated SEFA. As soon as Operation Care receives a grant agreement, the Fiscal Director and Executive Director will review it to see if there are federal funds. If so, the Fiscal Director will enter the grant, along with the CFDA number and all other pertinent information into the SEFA. At the end of the grant year, the SEFA will then be updated to reflect Federal Expenses. The updated SEFA will then be provided to the Executive Director. Name of Contact Person: Ashley Carnicello, Executive Director, (209) 223-2897 ashley@operationcare.org Bruce Platt, Fiscal Director (209) 223-2897 bruce@operationcare.org Projected Completion Date: SEFA will be updated by June 15, 2024 and will continue to be updated as needed.
View of Responsible Official and Corrective Action Plan: Haven House has identified the weakness of meeting the reporting requirements and will continue to work closely with granters to seek clarification to ensure we fully understand the agreements. Haven House will submit required monthly or quart...
View of Responsible Official and Corrective Action Plan: Haven House has identified the weakness of meeting the reporting requirements and will continue to work closely with granters to seek clarification to ensure we fully understand the agreements. Haven House will submit required monthly or quarterly reports as noted in contracts. Haven House will incorporate reports into our monthly close. Corrective Action Plan Timeline: Fiscal Year 2024 Designation of Employee Position Responsible for Meeting Deadline: Executive Director, CPA Firm
Finding 397702 (2023-003)
Significant Deficiency 2023
View of Responsible Official and Corrective Action Plan: Haven House has identified the weakness of late data collection form. We will be incorporating deadlines into our monthly close checklist to ensure submission of reports in a timely manner to ensure that future audits and data collection are c...
View of Responsible Official and Corrective Action Plan: Haven House has identified the weakness of late data collection form. We will be incorporating deadlines into our monthly close checklist to ensure submission of reports in a timely manner to ensure that future audits and data collection are completed in a timely manner. Corrective Action Plan Timeline: Fiscal Year 2024 Designation of Employee Position Responsible for Meeting Deadline: Executive Director, CPA Firm
Finding 397692 (2023-002)
Significant Deficiency 2023
Corrective Action Plan Significant Deficiency - Reporting Finding 2023-002 Roof Above will develop a policy for formal documentation of review of required reports prior to submission. Contact person responsible for corrective action: Kaedon Grinnell, Chief Program Officer Anticipated completion d...
Corrective Action Plan Significant Deficiency - Reporting Finding 2023-002 Roof Above will develop a policy for formal documentation of review of required reports prior to submission. Contact person responsible for corrective action: Kaedon Grinnell, Chief Program Officer Anticipated completion date: September 30, 2024
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....
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 Amount $0 Status: Corrective action in progress Corrective Action: The Authority does not concur with the auditor’s conclusion that it needs to update the state plan to include all methods and procedures used to safeguard against unnecessary utilization of care and services. The Authority has received written guidance from the Centers for Medicare & Medicaid Services (CMS) that it does not need to individually list the methods and procedures but rather complete the template document in the state plan and select from a list of applicable methods. CMS approved this portion of the state plan effective July 1, 2023. The Authority has adequate internal controls to ensure compliance with utilization control requirements and partially concurs with the auditor’s recommendation related to implementing and monitoring a statewide surveillance and utilization control program. The Authority recently updated the Fraud and Detection System (FADS) and is in the process of updating policies and procedures related to FADS operation and the statewide surveillance and utilization control program. The FADS system triggers alerts and judgmental sampling is used by staff to assess risk and determine follow-up procedures. The system is in its early implementation phase and the Authority is still in the process of establishing written criteria. The conditions noted in this finding were previously reported in findings 2022-061, 2021-050, 2020-047, 2020-048, 2019-052, 2019-053, and 2018-047. Completion Date: Estimated December 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov
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 in progress Corrective Action: The Health Care Authority partially concurs with the audit finding. The Authority does not audit inpatient hospital cost reports because it is not a federal requirement. The Authority has updated the Washington Administrative Code and its State Plan to align with federal regulations. The Authority partially concurs with the auditor’s assertion that it does not audit hospital and financial and statistical records. The Authority contracts for audits of Disproportionate Share Hospitals which includes roughly half of the hospitals in Washington. These audits include other financial and statistical records and meet this requirement. The auditor was provided information regarding these audits. The Authority will develop a desk audit process to review the financial statements of Washington hospitals, as necessary, and will create policies and procedures related to this process. The Authority does not concur with the auditor’s conclusion that it does not audit hospital billings or have methodology, policies, or procedures related to these audits. The Authority conducts utilization review and payment integrity audits of inpatient hospitals on an ongoing basis, which includes verification of billed charges. This information is well-documented and was provided to the auditor during the audit. The Authority will continue to formally document its internal controls over this compliance area. The conditions noted in this finding were previously reported in findings 2022-060, 2021-051, and 2020-049. Completion Date: Estimated October 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov
Finding: The Department of Social and Health Services’ Aging and Long-Term Support Administration did not have adequate internal controls over and did not comply with requirements to ensure timely investigation of complaints of client abuse and neglect at Medicaid residential facilities. Questio...
Finding: The Department of Social and Health Services’ Aging and Long-Term Support Administration did not have adequate internal controls over and did not comply with requirements to ensure timely investigation of complaints of client abuse and neglect at Medicaid residential facilities. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees that it did not meet the Immediate Jeopardy and Non-Immediate Jeopardy complaint timelines due to the backlog created by the public health emergency and a 20 percent staff vacancy rate. The Department does not agree that it was due to lack of internal controls. Over the past two years, the Department had 30 new staff who were not certified to complete investigations independently; there were only three available trainers who spent the majority of their time in 2022 and early 2023 addressing training needs. Once staff completed the training and applied for certification, testing sites were limited resulting in staff having difficulty finding available testing slots. In late 2022, this process transitioned from in-person to virtual which provided greater opportunity for timelier certification. As of March 31, 2023, all staff have the required certification, and the training backlog has been resolved. As of February 2024, Immediate Jeopardy (2 days) complaints were completed on time. The Department implemented a procedure to review the status of intakes at the regional level monthly to ensure timelines continue to remain compliant for Immediate Jeopardy complaints. By June 2024, the Department will ensure Non-Immediate Jeopardy intakes are completed in a timely manner. Once the Department is in compliance with Non-Immediate Jeopardy complaints, the monthly review procedures will also be implemented. The conditions noted in this finding were previously reported in findings 2022-057 and 2021-054. Completion Date: Estimated June 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
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 ...
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 agrees with the finding. The Department agrees that it did not meet the Nursing Home Recertification Survey requirements, due to the backlog created by the public health emergency and a 20 percent staff vacancy rate. The Department does not agree that it was due to lack of internal controls. It was through applied internal controls that we identified the need to hire a contractor to assist with the recertification backlog to meet compliance requirements. As of March 2024, the Department met the 15.9-month recertification timeline. The 12.9-month statewide average is based on the overall average of months for all nursing home surveys, which included some of those surveys that were in a significant backlog due to the pandemic. Statistically, even when the state is meeting the 15.9-month timeframe for each home and lowering the number of months between surveys, it is expected that the bell curve average will take time to shift toward 12.9 months. The Department believes this will be achieved by January 2026. The conditions noted in this finding were previously reported in finding 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
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 93.778 93.778 COVID Amount $0 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees that it did not meet the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) Survey requirements, due to the backlog created by the public health emergency and a 20 percent staff vacancy rate. The Department does not agree that it was due to 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. As of March 2024, the Department: • Met the 15.9-month recertification timeline. • Created a statement of deficiency and plan of correction tracking tool in Smartsheet for each team in Residential Care Services to track deadlines. This system generates automatic email alerts to key staff on approaching deadlines and when recertification deadlines have arrived. The 12.9-month statewide average is based on the overall average of months for all ICF-IID surveys, which included some of those surveys that were in a significant backlog due to the pandemic. Statistically, even when the state is meeting the 15.9-month timeframe for each home and lowering the number of months between surveys, it is expected that the bell curve average will take time to shift toward 12.9 months. The Department believes this will be achieved by January 2026. The conditions noted in this finding were previously reported in findings 2020-053, 2019-061, 2018-052, 2017-042, 2016-037, 2015-045, 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
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 in progre...
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 in progress Corrective Action: The Department has a process to screen complaints for possible imminent danger and will evaluate current procedures to identify necessary changes to ensure initial screening dates are properly reflected for subsequent assessment and review. The Department will also strengthen internal controls to ensure our licensing and regulatory systems are sufficient in managing the process of handling all facilities complaints to capture the screening for imminent danger within two working days. Once that process is complete, the Department will perform quarterly audits to confirm and document that timely screening of complaints is taking place as required. The Department will also identify strategies to improve staffing challenges and stability. Completion Date: Estimated December 2024 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $0 Status: C...
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $0 Status: Corrective action in progress Corrective Action: The Department is strongly committed to ensuring the health, safety, and well-being of all children in care. The Department concurs with the finding and has taken the following actions: • In the fall of 2022, the Department began recruiting new staff to address staff turnover issues and providing training on child care licensing rules and regulations. • In November 2022, added new positions to assist supervisors with onboarding and training new staff and focused training on monitoring visits, caseload management, and health and safety requirements. • Implemented a data driven, phased in approach, to return staff to in-person field work after the COVID-19 pandemic: o In July 2022, implemented return to in-person field work by reducing pandemic level requirements and authorizing staff to visit providers on-site to assist with meeting health and safety requirements. o In February 2023, developed and implemented a field practice onboarding process to streamline training for newly hired staff on practices to support the annual monitoring of all licensed child care providers. o In the spring of 2023, prioritized monitoring visits to return to compliance with Child Care and Development Fund program health and safety requirements. • Conducted a root cause analysis to determine other underlying causes for missed monitoring visits and untimely follow-ups, and how to address them. • For license-exempt family, friend, and neighbor (FFN) providers, the Department: o Received approval from the Office of Child Care for a hybrid monitoring approach (in-person and virtual visits). o Dedicated staff resources to update the WA Compass system to include all health and safety requirements for FFNs and address data format issues. Completion Date: Agency Contact: The Department will continue to strengthen internal controls as follows: For licensed providers: • Create in-training licensing positions to assist with staff recruitment efforts. • Continue to track and monitor health and safety requirements with available tools until all WA Compass system development is completed. • Examine ways to secure resources to add additional full-time staff to support caseload needs. For FFN providers: • Continue to track and monitor FFN health and safety requirements with available tools until all WA Compass system development is completed. The conditions noted in this finding were previously reported in findings 2022-045, 2021-039, 2020-042, 2019-039, 2018-035, 2017-025, 2016-022 and 2015-024. Estimated July 2025 Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure it filed reports required by the Federal Funding Accountability and Transparency Act for the Child Care and Development Fund. Questioned Costs: Assi...
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure it filed reports required by the Federal Funding Accountability and Transparency Act for the Child Care and Development Fund. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Status: Corrective action complete Corrective Action: The Department concurs with the finding. During the audit period, the Department experienced a high level of staff turnover and vacancy rates resulting in missed and inaccurate Federal Funding Accountability and Transparency Act (FFATA) reporting. As of October 2023, the Department implemented the following corrective actions: • Reviewed written policies and procedures with cost allocation and grant management staff. • Corrected the FFATA reports in question and submitted them in the Subaward Reporting System. The Department is committed to strengthening internal controls and complying with FFATA reporting requirements. Management will continue to monitor the process to ensure future reports are submitted accurately and completely. Completion Date: October 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with client eligibility requirements for child care services paid with the Child Care and Development Fund and Temporary Assistance for Needy Families funds. Questioned Costs: ...
Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with client eligibility requirements for child care services paid with the Child Care and Development Fund and Temporary Assistance for Needy Families funds. Questioned Costs: Assistance Listing # 93.558 93.575 93.575 COVID-19 93.596 Status: Corrective action in progress Corrective Action: The Child Care and Development Fund (CCDF) program was previously managed by the Department of Social and Health Services and the Department of Early Learning. Since the program transitioned in 2019, the Department has been making efforts to strengthen internal controls over payments to child care providers and other CCDF grant requirements. The Department will continue to maintain internal controls using our program integrity procedures, utilizing a combination of centralized and local case reviews to identify error trends, identify root causes, and develop solutions to the root causes. To address the fiscal year 2023 eligibility audit findings, the Department will: • Conduct root cause analysis of internal audit findings, particularly for cases with errors due to household composition and approved activities, and develop appropriate corrective actions as needed. • Develop and deliver updated household composition training for all staff. • Improve and publish the desk aid outlining simplified eligibility determination process that includes procedures for those families who do not have an approved activity. The conditions noted in this finding were previously reported in findings 2022-036, 2021-035, 2020-039, 2019-032, 2018-030, 2017-026, 2016-023, 2015-026, 2014-026, 2013-017 and 2012-30. Completion Date: Estimated July 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov
Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it filed reports required by the Federal Funding Accountability and Transparency Act. Questioned Costs: Assistance Listing # 93.044 93.044 COVID-19 93...
Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure it filed reports 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 in progress 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. By July 2024, the Department will collaborate with the Administration of Community Living to develop a plan to address the FFATA reporting backlog in state fiscal years 2022 and 2023, and to ensure all FFATA reports are entered in FSRS for all previous years. Completion Date: Estimated July 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
Finding: The 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 Prevention and Treatment of Substance Abuse. Questi...
Finding: The 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 Prevention and Treatment of Substance Abuse. Questioned Costs: Assistance Listing # 93.959 93.959 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Authority concurs with the finding. The Authority implemented the following to comply with the reporting requirements: • Office of Contracts and Procurement includes a Federal Funding Accountability and Transparency Act (FFATA) form as the last attachment in all subawards and ensures it is complete prior to forwarding it to Grants Accounting. • Grants Accounting staff were trained on an interim process to routinely monitor FFATA contracts forwarded by the Office of Contracts and Procurement and enter agency information into the FFATA Subaward Reporting System. The Authority will establish a validation process to ensure executed subawards are identified for reporting and completed reports are reviewed. The Authority will also formalize internal processes into procedures and continue to provide training to staff involved in the process. The conditions noted in this finding were previously reported in findings 2022-069 and 2021-058. Completion Date: Estimated June 2024 Agency Contact: William Sogge, CPA, CIA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov
Finding: The Health Care Authority did not have adequate internal controls to ensure payments to providers for the Block Grants for Prevention and Treatment of Substance Abuse program were allowable and met period of performance requirements. Questioned Costs: Assistance Listing # 93.959 93....
Finding: The Health Care Authority did not have adequate internal controls to ensure payments to providers for the Block Grants for Prevention and Treatment of Substance Abuse program were allowable and met period of performance requirements. Questioned Costs: Assistance Listing # 93.959 93.959 COVID-19 Amount $3,447,346 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 2022-067, 2021-057, and 2020-059. Completion Date: Not applicable Agency Contact: William Sogge, CPA, CIA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov
View Audit 306534 Questioned Costs: $1
Finding: The Department of Social and Health Services did not have adequate internal controls to ensure individuals are eligible to receive benefits for the Money Follows the Person program. Questioned Costs: Assistance Listing # 93.791 Amount $0 Status: Corrective action complete Correc...
Finding: The Department of Social and Health Services did not have adequate internal controls to ensure individuals are eligible to receive benefits for the Money Follows the Person program. Questioned Costs: Assistance Listing # 93.791 Amount $0 Status: Corrective action complete Corrective Action: The Department partially agrees with the finding. The Department agrees that the Financial and Social Services Communication (14-443) forms were not provided to terminate the enrollment of the four exceptions identified in the finding. However, in those exceptions, the Roads to Community Living (RCL) disenrollment communication was made in accordance with the existing Nursing Facility Case Management policy as defined in Chapter 10 of the Long-Term Care (LTC) Manual. In addition, all clients met eligibility criteria for RCL services or were converted to another Home and Community Based program within the 365-day RCL demonstration year limitation. In these cases, the client was converted to a state plan or waiver with the new program start date noted on the 14-443 forms. The 14-443 form is a communication tool used by the Department’s public benefit specialists. For Modified Adjusted Gross Income (MAGI) enrolled Medicaid participants, benefits are managed by the Washington State Health Care Authority and the 14-443 form is not required or used by the Department’s public benefit specialists. This MAGI beneficiary communication detail was not articulated in the RCL chapter of the LTC Manual. As of May 2024, the Department updated Chapter 29 of the LTC Manual to clarify instructions related to when the 14-443 form must be completed for MAGI participants and what needs to be included on the form when it is required. Completion Date: May 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov
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 93.775 93.777 93.777 COVID 93...
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 93.775 93.777 93.777 COVID 93.778 93.778 COVID Amount $0 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority does not concur that four providers did not receive a proper license check, nor that the backdated provider was noncompliant with regulations prior to receiving a National Provider Identifier (NPI). When a provider’s license expires, the Authority enters an end date for the provider taxonomy to prevent future payments. The Authority does not pay claims without an NPI and this is compliant with federal requirements. Corrective action has been in process to address revalidation issues. 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 developing additional procedures to strengthen internal controls over provider enrollment. The conditions noted in this finding were previously reported in findings 2022-055, 2021-047, 2020-046, 2019-048, 2018-042, 2017-033, and 2016-035. Completion Date: Estimated December 2024 Agency Contact: William Sogge, CPA, CIA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov
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 Amount $0 Status: Corrective...
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 Amount $0 Status: Corrective action in progress Corrective Action: Completion Date: The Authority partially concurs with the finding. Audited financial reports: The Authority agrees it allowed Managed Care Organizations (MCO) to submit annual audited financial reports in accordance with Statutory Accounting Principles to be consistent with the standards used by the Washington State Office of the Insurance Commissioner. The Authority will amend contract language to require MCOs to submit audited financial reports prepared in accordance with Generally Accepted Accounting Principles and Generally Accepted Auditing Standards, in order to comply with federal requirements. The Managed Care Oversight Audit Plan details the scheduled audits and prioritizes the various required audits. Going forward, the audit plan will list more specific information regarding the requirements and these changes will be added to the strategic plan. Periodic audits: The Authority does not concur with the auditor’s opinion that periodic audits must be “conducted and fully complete” at least once every three years. The federal regulations found in 42 CFR §438.602 specifically states: “The State must periodically, but no less frequently than once every 3 years, conduct, or contract for the conduct of, an independent audit…”. The term “complete” is not included in the federal regulations. The Authority will reach out to the Centers for Medicare & Medicaid Services to confirm its interpretation of the regulation. The conditions noted in this finding were previously reported in findings 2022-054 and 2021-048. Estimated July 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov
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 Amount ...
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 Amount $0 Status: Corrective action in progress Corrective Action: 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 utilizes grant-level management for 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. 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. In response to the auditor’s recommendations, the Department will: • Review internal controls and federal requirements related to SSBG reporting. • Develop and maintain a business process that would allow adjustments to include transaction level data. Completion Date: Estimated December 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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