Corrective Action Plans

Finding 398038 (2023-001)

Material Weakness 2023

WA

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

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Riverside School District No. 416 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of ...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Riverside School District No. 416 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Lisa Bjorklund, Business Manager Riverside School District No. 416 34515 N Newport Hwy Chattaroy, WA 99003-9734 Corrective action the auditee plans to take in response to the finding: In the future the district will comply with the federal prevailing wage requirements as part of our internal control process. Riverside will provide a weekly statement for all federal prevailing wage contracts; contracts will have all applicable Davis Bacon language in the contract prior to the start of any work. Riverside will comply with all applicable under Title 2 CFR Part 200, Title 29 CFR Section 3.3, and Title 29 CFR Section 5.5. Anticipated date to complete the corrective action: The corrective action will be in place as of May 20, 2024.

View Audit 306759

Finding 398037 (2023-001)

Material Weakness 2023

Rochester School District No. 401

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Rochester School District No. 401 September 1, 2022 through August 31, 2023 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Re...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Rochester School District No. 401 September 1, 2022 through August 31, 2023 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, and restricted purpose requirements. Name, address, and telephone of District contact person: Jill Pratt, Business Manager 10140 Hwy 12 SW Rochester, WA 98579 360-273-5536 Corrective action the auditee plans to take in response to the finding: We do not concur with the finding because 1,898 students were identified as having “unmet need” and 1,000 Chromebooks were purchased with grant funds. However, in the future we will document our processes differently. The District did conduct a survey of families and identified 1,898 students were in need of a school issued device. This grant purchased 1,000 Chromebooks. Every student in Rochester received a district issued Chromebook. In our inventory process, we did not tie the newly purchased Chromebooks to students identified as having a need; however, all those in need received a district device. Even though we locally determined every student had a need in order to succeed at remote learning, moving forward, we will ensure the federally purchased devices are checked out specifically to those determined to have an “unmet need” based on the federal definition. Anticipated date to complete the corrective action: We will work with the FCC to resolve this issue according to their timeline.

View Audit 306754 Questioned Costs: $1

Finding 398025 (2023-001)

Material Weakness 2023

Southside School District No. 42

WA

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

Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Paul Wieneke, Southside School District 161 SE Collier Rd Shelton, WA 98584 (360) 426-8437 Corrective ac...

Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Paul Wieneke, Southside School District 161 SE Collier Rd Shelton, WA 98584 (360) 426-8437 Corrective action the auditee plans to take in response to the finding: When engaging in any future state or federally funded capital project, the district will implement further internal controls to ensure compliance with all prevailing wage requirements. The district will keep a record of communication with the contractor, noting the date and time that weekly prevailing wages are monitored and are confirmed as accurate. The district will provide additional training to ensure staff overseeing compliance with federal programs are aware of all applicable requirements. Anticipated date to complete the corrective action: May 6, 2024

View Audit 306722

Finding 397987 (2023-010)

Significant Deficiency 2023

Boys and Girls Club of Dane County, Inc.

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Recommendation: Timecards should reflect all time, or 100% effort of each employee’s total hours actually spent on work within the scope of his or her employment regardless of how many or how few hours an employee works. Effort certification must reflect actual work performed and cannot be budget dr...

Recommendation: Timecards should reflect all time, or 100% effort of each employee’s total hours actually spent on work within the scope of his or her employment regardless of how many or how few hours an employee works. Effort certification must reflect actual work performed and cannot be budget driven or assigned. A written time and effort policy and procedures should be designed and implemented to meet grantor requirements and recordkeeping requirements of the organization. Ac􀆟on Taken: A cost allocation plan has now been established and will be reviewed by our Board. Timecards for all staff, including salaried staff, are now being filled out with actual hours spent per grant versus budgeted hours and for each grant coded, there are high level comments to explain what work was accomplished for the grant. There is also now a Financial Specialist on staff that reviews timecards for accuracy in this regard. The contact person responsible for this corrective action plan is Wendi Speed, CFO, as well as the HR team that will implement the policy. The anticipated completion date is June 30, 2025.

View Audit 306700

Finding 397986 (2023-009)

Material Weakness 2023

Boys and Girls Club of Dane County, Inc.

WI

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Recommendation: Additional procedures should be designed, implemented, and documented for allowable costs to ensure documentation of review and approval of allowable costs to be charged to the federal award. The accounting system configurations should be modified to require segregation of duties for...

Recommendation: Additional procedures should be designed, implemented, and documented for allowable costs to ensure documentation of review and approval of allowable costs to be charged to the federal award. The accounting system configurations should be modified to require segregation of duties for all transactions. For journal entries, a documented review and approval should be performed by a finance committee member on a monthly basis. Ac􀆟on Taken: BGCDC has received instructions on how to configure the Accounts Payable module to incorporate the proper approval process. We are in the process of making that update. In addition, for any journal entries made the by CFO, a monthly list will go to the Finance Committee for review. The CFO tries to not make journal entries, but with limited Finance staff and a large workload, this is often inevitable. The logical approvals would come from Finance Committee. The contact person responsible for corrective action is Wendi Speed, CFO. The anticipated completion date is June 30, 2025.

View Audit 306700

Finding 397985 (2023-008)

Material Weakness 2023

Boys and Girls Club of Dane County, Inc.

WI

Questioned Costs Subrecipient Monitoring § 200.332

Recommendation: Procedures for subrecipient monitoring to meet federal statutes, regulations, and terms and conditions of the awards should be developed and documented. Internal controls should be designed, implemented, and documented within the subrecipient monitoring procedures to ensure complianc...

Recommendation: Procedures for subrecipient monitoring to meet federal statutes, regulations, and terms and conditions of the awards should be developed and documented. Internal controls should be designed, implemented, and documented within the subrecipient monitoring procedures to ensure compliance with 2 CFR section 200.332. Subrecipient monitoring activities should be performed and documented. Ac􀆟on Taken: BGCDC is working on an updated policy and procedure manual that is conducive to Uniform Guidance. The addition of a Compliance Department will aid in adhering to the appropriate monitoring procedures regarding subawards. The contact persons responsible for this corrective action plan are Alan Branch, Sr VP of Compliance and Workforce Development, the new Compliance Director, Wendi Speed, CFO, and the entire Finance Team. The anticipated completion date is June 30, 2025.

View Audit 306700 Questioned Costs: $1

Finding 397984 (2023-007)

Material Weakness 2023

Boys and Girls Club of Dane County, Inc.

WI

Questioned Costs Subrecipient Monitoring Reporting § 200.302 § 200.328 § 200.329

Recommendation: Internal controls over reporting should be designed, implemented, and documented to ensure compliance with 2 CFR section 200.302(b)(2), including who is responsible, what they are reviewing for, when reviews are to take place, and how documentation of the controls will be maintained....

Recommendation: Internal controls over reporting should be designed, implemented, and documented to ensure compliance with 2 CFR section 200.302(b)(2), including who is responsible, what they are reviewing for, when reviews are to take place, and how documentation of the controls will be maintained. The general ledger should be set up to properly capture and track expenses as well as budgets prepared and approved with the actual costs expected to be incurred. Reports should be reconciled to the general ledger. Budgets should be complete and include all line items and not just include all expenses under supplies. Ac􀆟on Taken: This is a project Finance team is currently working on. The new Compliance Director will manage the grant writing process. During the grant and award process, Compliance, the Program with award, and Finance will establish an appropriate budget which, in turn, will be reflected in general ledger and monitored by the team. The contact persons responsible for this corrective action plan are Alan Branch, Sr VP of Compliance and Workforce Development, the new Compliance Director, Wendi Speed, CFO, and the entire Finance Team. The anticipated completion date is June 30, 2025.

View Audit 306700 Questioned Costs: $1

Finding 397982 (2023-005)

Material Weakness 2023

Boys and Girls Club of Dane County, Inc.

WI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.403

Recommendation: Transactions should be recorded in accordance with GAAP with a review and approval for financial reporting as well as for compliance with allowability requirements. Training on cost principles per the Uniform Guidance should be provided to the finance department and program managers....

Recommendation: Transactions should be recorded in accordance with GAAP with a review and approval for financial reporting as well as for compliance with allowability requirements. Training on cost principles per the Uniform Guidance should be provided to the finance department and program managers. Ac􀆟on Taken: This transaction happened early on when the WIG grant was first awarded. Soon after, it was apparent this had been done incorrectly. The current Finance staff has attended a two-day Uniform Guidance training course and continues to read and review 2 CFR 200 regularly. If a transaction is in question, we reach out to auditors/consulting team. The corrective action planned is continual training on Uniform Guidance and the addition of a Compliance Director to our team. The contact person responsible for the corrective action is Wendi Speed, CFO. The anticipated completion date is June 30, 2025.

View Audit 306700 Questioned Costs: $1

Finding 397980 (2023-002)

None 2023

Falcon Housing Corporation 023-Ee-122

MA

HUD Housing Programs Subrecipient Monitoring Eligibility

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2023-002: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuri...

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2023-002: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all current and new staff are trained on tenants’ 90-day EIV reports and ensuring they are generated within the required time period to verify tenant information promptly and help reduce errors in subsidy payments. ACTION TAKEN The Project will be monitoring use of the EIV system for move ins and recertifications.

View Audit 306693

Finding 397974 (2023-003)

Material Weakness 2023

State of South Dakota

SD

Subrecipient Monitoring

Finding No. 2023-003: Inadequate Internal Controls over Federal Funding Accountability and Transparency Act (FFATA) Reporting. The following are the actions that will be taken to come into compliance with FFATA on our Public Assistance Disaster Grants: • The Assistant Finance officer will work on...

Finding No. 2023-003: Inadequate Internal Controls over Federal Funding Accountability and Transparency Act (FFATA) Reporting. The following are the actions that will be taken to come into compliance with FFATA on our Public Assistance Disaster Grants: • The Assistant Finance officer will work on getting all past due records updated for FFATA, including the FY24 records, by May 31, 2024. • Office of Emergency Management’s, Recovery Branch Chief will review project worksheets and make sure the finance office has all updated information on any increases or decreases to all project worksheets for open disasters. • By May 31, 2024, the Director of Administrative Services and Assistant Finance officer will review our current processes and procedures for FFATA reporting for the Department of Public Safety. Make updates to that process to include internal controls ensuring reporting is done timely and accurately. Contact Person: Angie Lemieux, Director of Administrative Services Anticipated Completion Date: May 31, 2024

View Audit 306685

Finding 397911 (2023-003)

Significant Deficiency 2023

Pacific States Marine Fisheries Commission

OR

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.329

Timely Performance Reporting for Pacific Fisheries Data Program, 11.437; and Bipartisan Budget Act of 2018 (Disaster Relief Program), 11.022 Recommendation: CLA recommends for the Commission to implement stronger internal monitoring to ensure reports are completed by program managers and submitted ...

Timely Performance Reporting for Pacific Fisheries Data Program, 11.437; and Bipartisan Budget Act of 2018 (Disaster Relief Program), 11.022 Recommendation: CLA recommends for the Commission to implement stronger internal monitoring to ensure reports are completed by program managers and submitted to the Grants Manager timely to ensure ample time for internal review and upload to the Federal Agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will set an internal deadline at least one week prior to the external report due date. The Grant & Contract Specialist will coordinate with the Finance Officer to submit report timely in the event the Grant & Contract Specialist is absent. Name(s) of the contact person(s) responsible for corrective action: Michael Arredondo and Ngu Castro. Planned completion date for corrective action plan: October 15, 2023

View Audit 306634

Finding 397886 (2023-002)

Significant Deficiency 2023

Pacific States Marine Fisheries Commission

OR

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.318

Sufficient Documentation for Noncompetitive Proposals for Pacific Fisheries Data Program, 11.437 Recommendation: CLA recommends increased internal monitoring to ensure that noncompetitive procurements are sufficiently justified and that internal Sole Source Justification Forms are completed correct...

Sufficient Documentation for Noncompetitive Proposals for Pacific Fisheries Data Program, 11.437 Recommendation: CLA recommends increased internal monitoring to ensure that noncompetitive procurements are sufficiently justified and that internal Sole Source Justification Forms are completed correctly and retained for all vendors procured under noncompetitive methods. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will modify its subcontractor request form and PO form to require competitive supporting documents or non-competitive justification documents to be attached with the subcontractor request or PO form. Contract Specialist and Purchasing Specialist will review request package to ensure all required paperwork completed properly before moving forward with the process. In the pipe line, Requisition Module in Navision Software will be designed to put a hard stop if a purchase order of $10,000 or greater is missing supporting document for competitive/non-competitive procurements. Name(s) of the contact person(s) responsible for corrective action: Kathy Ameral and Michael Arredondo. Planned completion date for corrective action plan: October 15, 2023

View Audit 306634 Questioned Costs: $1

Finding 397877 (2023-001)

Material Weakness 2023

Accord

MN

Internal Control / Segregation of Duties Eligibility Subrecipient Monitoring § 200.303

Compliance and Controls over Compliance – Eligibility Home Investment Partnership Program, AL# 14.239 Material Weakness Accord did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual performing...

Compliance and Controls over Compliance – Eligibility Home Investment Partnership Program, AL# 14.239 Material Weakness Accord did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual performing the initial determination or annual reexamination. Actions Taken or Planned: Management agrees with this finding. As of December 31, 2023, the Organization has sold all properties financed by HOME funds. Contact Persons: Robert Pickering, Chief Financial Officer

View Audit 306612

Finding 397864 (2023-001)

None 2023

Tannersville Housing Development Fund Company, Inc.

NY

Subrecipient Monitoring Reporting § 200.512

Finding #2023-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Tannersville Housing Development Fund Com...

Finding #2023-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Tannersville Housing Development Fund Company Inc. agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Molly Whitbeck, Executive Director, at (518)943-6700.

View Audit 306602

Finding 397863 (2023-001)

None 2023

Orchard Housing Development Fund Company, Inc.

NY

Subrecipient Monitoring Reporting § 200.512

Finding #2023-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Orchard Housing Development Fund Company,...

Finding #2023-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Orchard Housing Development Fund Company, Inc. agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Molly Whitbeck, Executive Director, at (518) 943-6700.

View Audit 306601

Finding 397710 (2023-001)

None 2023

City of Arcata

CA

Subrecipient Monitoring Reporting

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.

View Audit 306563

Finding 397709 (2023-002)

Significant Deficiency 2023

Operation Care

CA

Reporting Subrecipient Monitoring Significant Deficiency

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.

View Audit 306556

Finding 397704 (2023-004)

None 2023

Haven House INC

NM

Subrecipient Monitoring HUD Housing Programs Special Tests & Provisions

View of Responsible Official and Corrective Action Plan: Haven House has identified the weakness of wage rate requirements, moving forward we will incorporate the required clause in contract when required. Corrective Action Plan Timeline: Fiscal Year 2024 Designation of Employee Position Responsible...

View of Responsible Official and Corrective Action Plan: Haven House has identified the weakness of wage rate requirements, moving forward we will incorporate the required clause in contract when required. Corrective Action Plan Timeline: Fiscal Year 2024 Designation of Employee Position Responsible for Meeting Deadline: Executive Director

View Audit 306555

Finding 397692 (2023-002)

Significant Deficiency 2023

Roof Above, Inc.

NC

Subrecipient Monitoring Reporting Significant Deficiency

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

View Audit 306553

Finding 397679 (2023-003)

None 2023

Stevensville Public Schools

MT

Subrecipient Monitoring

FINDING 2023-003: Audit Deadline Response: The district will ensure that all required paperwork to comply with audit is provided to auditors in a timely fashion.

View Audit 306539

Finding 397578 (2023-082)

Material Weakness 2023

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....

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

View Audit 306534

Finding 397577 (2023-081)

Material Weakness 2023

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 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

View Audit 306534

Finding 397576 (2023-080)

Material Weakness 2023

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 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

View Audit 306534

Finding 397575 (2023-079)

Material Weakness 2023

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 ...

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

View Audit 306534

Finding 397574 (2023-078)

Material Weakness 2023

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 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

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