Corrective Action Plans

Finding 442878 (2022-002)

Material Weakness 2022

Copa Health, Inc.

AZ

Allowable Costs / Cost Principles Eligibility Internal Control / Segregation of Duties § 200.303

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionCFDA #93.498Finding Summary: The Organization?s final expenditure listing identified as eligible and claimed under theProvider Reli...

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionCFDA #93.498Finding Summary: The Organization?s final expenditure listing identified as eligible and claimed under theProvider Relief Fund program lacked documentation of its review by a separate individual outside of thepreparer. The support for two out of 60 expenditures tested differed in amounts from the amount on thetracking spreadsheet. Three of the 60 invoices did not include evidence of approval for payment.Responsible Individuals: CFO Martin Quintana, and Controller Gladys LopezCorrective Action Plan: We reviewed the internal controls and provided better separation of duties in the process.Steps were added to the process that entail a review of the preparers? work by a second person before they aresubmitted to the Controller and/or the Chief Financial Officer for approval. Will also establish a process forensuring full review of financial statements.Anticipated Completion Date: By 11/30/2023

View Audit 312508

Finding 442867 (2022-005)

Significant Deficiency 2022

United Way of Greater Cleveland

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are app...

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are applied to the correct period for the correct amount after the Accounting Coordinator inputs the data to ensure that Federal funds are reimbursed accurately and in the appropriate period

View Audit 312506 Questioned Costs: $1

Finding 442866 (2022-004)

Significant Deficiency 2022

United Way of Greater Cleveland

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are app...

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are applied to the correct period for the correct amount after the Accounting Coordinator inputs the data to ensure that Federal funds are reimbursed accurately and in the appropriate period.

View Audit 312506 Questioned Costs: $1

Finding 442861 (2022-003)

Material Weakness 2022

Anthem Strong Families

TX

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Management will ensure that accrued expenses are reviewed in detail at grant year end to ensure only costs incurred prior to year end are accrued and reported as grant expenditures.

View Audit 312505

Finding 442859 (2022-002)

Significant Deficiency 2022

The Cleveland Play House

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.302 § 200.403

Finding Number: 2022-002Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 fiscal yearwhich resulted in several vacancies, including the Director of Finance position, for a significant portion ofthe year. As a result, many of the reports that are standard practice...

Finding Number: 2022-002Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 fiscal yearwhich resulted in several vacancies, including the Director of Finance position, for a significant portion ofthe year. As a result, many of the reports that are standard practice in our organization were not beingcompleted. In addition, the filing of certain documentation to support expenditures was not being doneconsistently. The Director of Finance position was filled in the fall of 2022. As a result, documentationof allowable expenditures is being addressed for the fiscal 2023 audit.In addition to turnover, the organization transitioned to a new general ledger system with a new chartof accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certaindata pertaining to the federal programs was not being captured. Management has informed all staff ofthe requirements to track federal programs within the general ledger accounts.Anticipated Completion Date: June 30, 2023Responsible Contact Person: Erica Tkachyk, Director of Finance

View Audit 312500 Questioned Costs: $1

Finding 442852 (2022-004)

Material Weakness 2022

South Montgomery Community School Corporation

IN

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

FINDING 2022-004Contact Person Responsible for Corrective Action: Kristin CharlesContact Phone Number: 765-866-0203Views of the Responsible Official: The School Corporation is in agreement with the Finding.Description of Corrective Action Plan: This should not be an issue moving forward as now writ...

FINDING 2022-004Contact Person Responsible for Corrective Action: Kristin CharlesContact Phone Number: 765-866-0203Views of the Responsible Official: The School Corporation is in agreement with the Finding.Description of Corrective Action Plan: This should not be an issue moving forward as now write our grant to be used for our Co-Op Bill and do not pay salaries directly. In the future if we plan to pay with Federal Funding, we will require time and effort logs.Anticipated Completion Date: 4/1/2023

View Audit 312499 Questioned Costs: $1

Finding 433356 (2022-026)

Significant Deficiency 2022

State of Louisiana

LA

Allowable Costs / Cost Principles Subrecipient Monitoring

Dear Mr. Waguespack,The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 10, 2023, regarding a reportable audit finding related to Inadequate Controls over Drug Rebate Collections. LDH appreciates the opportunity to prov...

Dear Mr. Waguespack,The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 10, 2023, regarding a reportable audit finding related to Inadequate Controls over Drug Rebate Collections. LDH appreciates the opportunity to provide this response to your office's findings.Finding: Inadequate Controls over Drug Rebate Collections.Recommendation: LDH should ensure that agency personnel are adequately monitoring contract provisions for the drug rebate program and follow-up procedures are performed for all drug rebate invoices that have not been fully collected or disputed in a timely manner.LDH Response: LDH does not concur with this finding and recommendation.LLA issued a finding April 14, 2022 regarding partially paid invoices. LDH responded to the finding on April 22, 2022 regarding 2021 procedures. LLA immediately audited SFY 2022 after the SFY 2021 finding. As a result, there was not enough time to build out the CAP before the end of the SFY22, June 30, 2022.Based on the finding and response in late April, it was determined Magellan Medicaid Administration would email labelers at the 45-day late letter mark. The 45-day mark for the May 2022 invoicing cycle was on July 11, 2022. The 45-day mark before that would have been April 11, 2022, before the finding.In the brief interim before the end of SFY 2022, measures were taken by LDH and Magellan (end of April, May & June) to begin setting up the mechanisms to address collections on partial payment accounts. First quarter partial payment accounts were addressed with the 45-day Dunning Notices, July 11, 2022 and are currently being monitored. Magellan has been manually sending Dunning Notices to all manufacturers that made partial payments. This procedural change is to help increase collection rates.Corrective Action Plan and progress addressing the findings are listed below:1) Magellan regularly provides LDH with an Aged Receivables and Disputes Dashboard. This visual spreadsheet shows open balance data for federal and supplemental rebate programs, along with original invoice information, collection rates, and open disputes over the past 4 quarters (starting the week of April 24, 2022). LDH holds weekly meetings with Magellan to review the data and recommend changes. The dashboard is updated quarterly.2) Magellan has built a team to work on rebate related manufacturer operations focused on accounts receivables and disputes.? Magellan has built a manufacturer-focused team.? Magellan has addressed partial payments by sending Dunning Notices to manufacturers.3) Magellan will begin emailing all labelers with outstanding balances. An email template is being created and will be provided to LDH during the week of April 24, 2022 for approval.? LDH approved an-email template. However, after additional consideration it was determined this was not needed.? Upon further review and discussion by LDH and Magellan it was determined that Magellan would not email all Labelers with outstanding balances over 150 days. The "late" letters Magellan sends to manufacturers at 45-day, 75-day, and 90-day marks were sufficient. The letters serve as a 60-day letter, per ODR statute. The 45-day and the 75- day letters can suffice as the reminder letter to be sent to the debtor to pay the debt within 60 days before transfer to ODR.4) Magellan will change its automated Dunning Notices process to include labelers that made partial payments. This procedural change will continue to help increase the collection rate.? Magellan began emailing all labelers with partial payments. Magellan sent the first email on 7/11/22 to all labelers that made partial payments to the 1Q22 invoices? The automated Dunning Notices process will be changed to include labelers that made partial payments as part of the RxLink implementation, which is planned to go live in February 2023.? In the interim, the updated process for late letters that includes partial payments has been:1. Dunning #IA sent through an automated process to labelers that made no payments- 45 days after original postmark2. Dunning #1B manually emailed to labelers that made partial payments and for which the total outstanding balance is greater than $25 - 45 days after original postmark.3. Dunning #2A sent through an automated process to labelers that made no payments - 75 days after original postmark4. Dunning #2B manually emailed to labelers that made partial payments and for which the total outstanding balance is greater than $25 - 75 days after original postmark5. Next Quarterly Invoice plus Prior Period Statement- includes total balance due for prior periods6. Dunning #3A sent through an automated process to labelers that made no payments - 90 days after original postmark7. Dunning #3B manually emailed to labelers that made partial payments and for which the total outstanding balance is greater than $25 - 90 days after original postmark8. Dunning #4 sent through an automated process to labelers that made no payments - 210 days after original postmarkEffective 02/2023, all dunning letters will be sent through an automated process to labelers that made no payments and to labelers that made partial payments. This will be part of RxLink Implementation.In regards to additional procedures for collection of partial payments, Magellan previously invoiced quarterly and included invoices for past quarters not fully paid in the subsequent quarter. In addition, after 210 days of not receiving payment in full, Magellan's Rebate team reviewed outstanding balances and reached out to manufacturers.You may contact Tara A. LeBlanc at (225) 219-7810 or via e-mail at Tara.LeBlanc@LA.GOV or Germaine Becks-Moody, Medicaid Program Manager at (225) 342-9479 or via email at germaine.becks-moody@la.gov with any questions about this matter.

View Audit 312391

Finding 433300 (2022-032)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles § 200.303

Dear Mr. Waguespack:Please allow this letter to serve as the official response for both the Management Letter and the Single Audit Report in reference to the finding concerning Control Weakness Relating to Foster Care Billings.The Office of Juvenile Justice (OJJ) does concur with the finding. The ag...

Dear Mr. Waguespack:Please allow this letter to serve as the official response for both the Management Letter and the Single Audit Report in reference to the finding concerning Control Weakness Relating to Foster Care Billings.The Office of Juvenile Justice (OJJ) does concur with the finding. The agency and LA Department of Public Safety (DPS), Office of Management and Finance, Financial Services, which is responsible for performing the back office functions for OJJ, has a responsibility for ensuring that the Foster Care administrative invoices are properly reviewed prior to submission to the Department of Children and Family Services (DCFS) for reimbursement. Inadequate review of the invoice submission for quarter ending December 2021 resulted in an overpayment of $128,236.00 from DCFS made to OJJ.Effectively immediately, an additional level of review and approval of the Foster Care administrative invoices will be added to the process. Samantha Dunbar, DPS Staff Accountant, will continue to prepare the invoices, and submit the invoice and supporting documentation to Wanda Armwood, DPS lead Staff Accountant for the first level review and approval. Once the Lead Accountant approves, the invoices and documentation will be forwarded to A'shli Oliver, DPS Accounting Manager, for the second level review and approval. Once the second level approval has been completed, the DPS Accounting Manager will submit the invoices and documentation to OJJ staff for final review and approval. Undersecretary, Jason Starnes will provide the final approval of the invoices after Karli Pullard, Program Manager at OJJ, and Cassandra Washington, Deputy Undersecretary at OJJ, have reviewed and approved the invoices submitted by DPS.

View Audit 312391 Questioned Costs: $1

Finding 433287 (2022-004)

Material Weakness 2022

State of Louisiana

LA

Allowable Costs / Cost Principles § 200.430

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated March 8, 2023, regarding a reportable audit finding related to Inadequate Controls over Payroll. This finding pertains to the following programs in t...

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated March 8, 2023, regarding a reportable audit finding related to Inadequate Controls over Payroll. This finding pertains to the following programs in the Office of Public Health (OPH): Special Supplemental Nutrition Program for Women, Infants and Children (WIC), Public Health Emergency Preparedness (PHEP), Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), and HIV Prevention Activities (HIV). LDH appreciates the opportunity to provide this response to your office's finding.Finding: Inadequate Controls over Payroll - OPHRecommendation: OPH should ensure employees comply with existing policies and procedures, including certifying and approving electronic time statements in a timely manner.LDH Response: LDH concurs with the finding and concurs with the recommendation.As part of a comprehensive agency-wide plan to address this finding, OPH has developed a corrective action plan to enact control measures and monitor the certification and approval of electronic time statements.OPH has a Time Entry Policy in final draft form that will be in place and distributed to all staff by March 24, 2023. This policy includes employee, supervisor, and time administrator responsibilities regarding the certification and approval of electronic time statements.OPH has a new compliance position, and will be reviewing compliance of policies and procedures across the agency. Controls over payroll, including the electronic certification and approval of time statements, will be one of the areas of focus for this position. The position will be filled on March 20, 2023.Each pay period, LDH Human Resources sends all LDH and OPH time administrators an email that includes Time Administrator Payroll Timelines and reports that must be run each pay period. This also includes reports that indicate errors that must be corrected prior to payroll close and the eCertification Report used to identify any electronic time statements that have not been certified or approved for follow-up.LDH Human Resources has in-person trainings currently scheduled for LDH and OPH time administrators across the state.You may contact Devin George, OPH Deputy Assistant Secretary, by telephone at (225) 342-2655, or by email at devin.george@la.gov.

View Audit 312391

Finding 433282 (2022-016)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles

Dear Mr. Waguespack:Listed below is the University's response to the finding regarding Control Weaknesses over Higher Education Emergency Relief Funds RequirementsFINDING: Control Weaknesses over Higher Education Emergency Relief Funds RequirementsRESPONSE: Southern University - Baton Rouge (SUBR) c...

Dear Mr. Waguespack:Listed below is the University's response to the finding regarding Control Weaknesses over Higher Education Emergency Relief Funds RequirementsFINDING: Control Weaknesses over Higher Education Emergency Relief Funds RequirementsRESPONSE: Southern University - Baton Rouge (SUBR) concurs in part with the above noted finding.The University does not concur that this is the second consecutive year to have the same reported weaknesses. The University implemented corrective action in the prior year. Of the four errors included in the prior year audit finding, the University corrected three of the errors. The error related to loss revenue was corrected during the prior year audit. The below error was not a part of the condition of the prior year audit finding. In addition, the timely implementation of recommendations demonstrates the University's management desire to be accountable for, and a willingness to improve their operations.The University does concur that during the current year a formula error did result in a calculation of loss revenue using the four (4) year combined average instead of the 5 (five) year combined average revenue as baseline revenue. This resulted in an overdraw of funds in fiscal year 2022 by $1.9 million. However, the University had a $2.5 million under draw from fiscal year 2021 to offset this, resulting in a net under draw of approximately $600,000.The University will continue to review the USDOE website and attend webinars for guidance related to HEERF reporting requirements. Management will continue to monitor the concerns noted in this finding.Mr. Flandus McClinton, Vice President for Finance and Business Affairs, is responsible for implementing and monitoring corrective actions. The projected deadline to finalize the review of the concern brought to the University's attention with this audit finding is June 30, 2023.If you have any questions or require additional information, please contact Mr. Flandus McClinton, Jr. at 225- 771.6278.

View Audit 312391 Questioned Costs: $1

Finding 433275 (2022-017)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles § 200.430

Dear Mr. Waguespack:Below is the Law Center's response to the Finding ' Improper Payments to Southern University Law Center Employee".FINDING: Improper Payments to Southern University Law Center Employee " .RESPONSE:Southern University Law Center (SULC) concurs with the finding on Improper Payments ...

Dear Mr. Waguespack:Below is the Law Center's response to the Finding ' Improper Payments to Southern University Law Center Employee".FINDING: Improper Payments to Southern University Law Center Employee " .RESPONSE:Southern University Law Center (SULC) concurs with the finding on Improper Payments to Southern University Law Center Employee.SULC has taken the following steps to ensure that an employee' s employment status is revised immediately to prevent such occurrences in the future. With respect to employee notices of resignations, retirements , or other terminations (terminations) , SULC will perform the following procedures.1. Establish a line of communication with specific Human Resource (HR) personnel addressing terminations of employees, including EPAF processing.2. Establish a timeline for EPAF processing.3. Immediately notify the web-time payroll approver, Supervisor and or Director, and Vice Chancellor for the department of the employee's terminal employment status.Terry R. Hall, Vice Chancellor for Finance and Administration will be responsible for the corrective action plan. Procedures for the correction plan have been initiated and will be fully operable during the fiscal year 2022-2023.

View Audit 312391 Questioned Costs: $1

Finding 433258 (2022-008)

None 2022

State of Louisiana

LA

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

Dear Mr. Waguespack:The Department of Children and Family Services has reviewed the finding ?Improper Employee Activity in Federal Program?. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. Each...

Dear Mr. Waguespack:The Department of Children and Family Services has reviewed the finding ?Improper Employee Activity in Federal Program?. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. Each employee of the Department of Children and Family Services (DCFS), as a new hire and annually, must sign and date form DCFS CS 4 Acknowledgement of Agreement to Comply with DCFS Policy Regarding Prohibited Activities and Employees Working on Cases of Relatives, Friends, Acquaintances, and/or Oneself.The Department?s Fraud and Recovery Unit initiates a review of each employee receiving benefits under the programs administered. An automated monthly report identifies all DCFS employees receiving assistance in the Supplemental Nutrition Assistance Program (SNAP) and all new cases are reviewed for eligibility by parish office staff. Any cases identified by parish office staff as suspect are submitted to the Fraud and Recovery Unit for investigation. Through their reviews, the Fraud and Recovery Unit identified improper activity by a DFCS employee. The employee was subsequently terminated and is required to repay the ineligible SNAP benefits. Additionally, the employee is barred from future employment with DCFS.DCFS reported this finding to the United States Department of Agriculture, Food and Nutrition Service, on the FNS 366B, as required. The Fraud and Recovery Unit has collected $78.00 of the debt and will continue to pursue recovery of the remaining $3,890.00 balance. Should the household cease to repay the balance the case will be referred to the Treasury Offset Program once the due process prerequisites are met.The Fraud and Recovery Unit also investigated two employees for payroll fraud. Both employees were determined to have received wages from DCFS and a secondary employer for the same hours worked. One of the employees was terminated from DCFS and the other employee resigned prior to the receipt of a termination letter. DCFS has recovered $11,349 from one former employee and is seeking recovery of the amount owed by the other former employee.DCFS will continue to investigate improper employee activities and emphasize the consequences of illegal acts. If you have any questions, please contact Rhonda Brown, Fraud and Recovery Unit Director, at Rhonda.Brown.DCFS@LA.GOV.

View Audit 312391

Finding 433257 (2022-006)

Material Weakness 2022

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.308 § 200.430

Dear Mr. Waguespack,Please find below our management response to the audit finding "Control Weakness and Noncompliance with Personnel Expenses Charged to Federal Awards".The University does not concur that this is a second consecutive year finding, but in fact the same one from FY2021.The completion...

Dear Mr. Waguespack,Please find below our management response to the audit finding "Control Weakness and Noncompliance with Personnel Expenses Charged to Federal Awards".The University does not concur that this is a second consecutive year finding, but in fact the same one from FY2021.The completion of FY2021 audit and the start of FY2022 audit did not allow the University time in between to correct the FY2021 finding.The following is timeline for the FY2021 finding.? Notification of potential finding was sent on 4/20/22.? Preliminary response request was sent on 5/26/22.? Preliminary finding response was submitted on 6/2/22.? Audit response request letter was sent on 6/6/22.? Audit response was submitted on 6/10/22.Sponsored Programs Finance Administration and Compliance (SPFAC) will continue the following corrective action provided in FY2021 and it will be overseen by Director of SPFAC.1. Update the current effort reporting and certification policy.2. Create and implement an internal user-friendly effort reporting system.3. Train faculty and staff on how to use the effort reporting and certification system.4. Track the effort certifications quarterly.5. For federal awards that follow CFR 200.201- Use of grant agreements (including fixed amount awards), cooperative agreements, and contracts, the University will internally track and certify the personnel effort cost separately as the billing is dictated by the issued task orders based on the estimated task order cost.

View Audit 312391 Questioned Costs: $1

Finding 433256 (2022-005)

Material Weakness 2022

State of Louisiana

LA

Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

Dear Mr. Waguespack,Thank you for the opportunity to respond to your office's finding related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff. LSUHSC-S concurs with the recommendations to address the f...

Dear Mr. Waguespack,Thank you for the opportunity to respond to your office's finding related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff. LSUHSC-S concurs with the recommendations to address the finding and provides the following response and corrective action plan.Recommendation:Management should monitor time and effort certifications completed by the departments and investigate and obtain justification from department personnel for untimely certifications as well as untimely adjustments and lack of supporting documentation for the adjustments to enforce established policies.Response and Corrective Action Plan:LSUHSC-S will continue to offer training classes and educational meetings to address the Federal requirements and ensure compliance. The training classes include one-on-one departmental meetings held by the Office of Sponsored Programs on new awards, Department Business Manager and Administrative Staff monthly meetings, and research personnel time and effort educational sessions. Emphasis will be placed on grant management organizational podcasts and classes for seasoned and new business staff, principal investigators, and institutional grant and contract support staff.LSUHSC-S will again review the procedures to address improvements for processing adjustments through PERs with sufficient justification and timely approvals and entry in Peoplesoft.Name of Contact(s) Responsible for Action PlanSheila Faour, CFO, Business and ReimbursementsJen Katzman, Assistant Vice Chancellor for Administration and Finance (with Departmental Business Managers)Bill Haacker, Assistant Director of Grants AccountingSteven McAlister, Associate Director of General AccountingAnnella Nelson, Assistant Vice Chancellor for Research DevelopmentAnticipated Completion Date: ContinuousRecommendation:Management should ensure adequate design and operating effectiveness of controls over expenses, including P-Card expenses, charged to federal awards to verify allowability of costs in accordance with federal requirements and grant terms and conditions prior to requesting reimbursement.Response and Corrective Action Plan:The transaction exceptions identified totaled approximately $1,200 with one transaction exceeding the allocated budget and two transactions being coded to an incorrect award number.To address the exceptions, LSUHSC-S is exploring implementation of additional Peoplesoft module vendor transaction utility, such as adding more approvers and requiring additional description of the purchase to assist the applicable departments in fulfilling their responsibilities in the transactional review area.LSUHSC-S will also add this responsibility role training as part of our continuing one on one meetings and educational classes.Name of Contact(s) Responsible for Action PlanSheila Faour, CFO, Business and ReimbursementsJen Katzman, Assistant Vice Chancellor for Administration and Finance (with Departmental Business Managers)Steven McAlister, Associate Director of General AccountingBill Haacker, Assistant Director of Grants AccountingAnnella Nelson, Assistant Vice Chancellor for Research DevelopmentAnticipated Completion Date: ContinuousRecommendation:Management should also consider implementing other complementary controls such as preventing costs from being charged to projects in the accounting system beyond the approved budget or period of performance.Response and Corrective Action Plan:LSUHSC-S has implemented a setting in Peoplesoft that prevents personnel expenditures on accounts over budget or beyond the performance period. The personnel expenditures are captured in a suspense account for review by departmental business staff to identify the appropriate funding. This setting will be expanded for more projects and non-personnel expenditures.Name of Contact(s) Responsible for Action PlanSheila Faour, CFO, Business and ReimbursementsJen Katzman, Assistant Vice Chancellor for Administration and Finance (with Departmental Business Managers)Steven McAlister, Associate Director of General AccountingBill Haacker, Assistant Director of Grants AccountingAnticipated Completion Date: June 30, 2023If you have questions or require additional information, please contact me at (318) 675-5230 or via email at cindy.rives@lsuhs.edu.

View Audit 312391

Finding 425827 (2022-007)

Material Weakness 2022

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2022-007 ? Allowable Costs/Cost PrinciplesHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoVirginia MasonFinding: At St. Mary?s Medical Center ? San Francisco ...

REFERENCE: 2022-007 ? Allowable Costs/Cost PrinciplesHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoVirginia MasonFinding: At St. Mary?s Medical Center ? San Francisco and Virginia Mason, controls over the requiredallowability criteria with regard to payroll expense were not performed and/or documented throughout the year.Corrective Action Plan: This finding has been corrected. At St. Mary?s Medical Center ? San Francisco, as of July2021 invoices were prepared using actual payroll as opposed to budget. At Virginia Mason, beginning in April 2022,managers receive notification from the payroll department of unapproved time cards that are waiting for approval.A reminder email is sent to managers and employees to approve and submit their time cards on time. Trainingsessions were implemented to instruct all employees and the managers of this requirement. Once the training hasbeen completed and employees or managers miss approving the timecard then disciplinary actions will be taken.Payroll sends out messages of outstanding timecards awaiting approval.Person Responsible: Doug Amarelo ? St. Mary?s Medical Center, San FranciscoRebecca Kiser ? Virginia MasonCompletion: April 2022

View Audit 312373

Finding 425679 (2022-015)

Significant Deficiency 2022

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2022-015 ? Allowable Costs/Cost PrinciplesMedical Assistance Program (Medicaid Cluster) (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Connected LivingFinding: At Dignity Health Connected Living, internal controls over the required allowabili...

REFERENCE: 2022-015 ? Allowable Costs/Cost PrinciplesMedical Assistance Program (Medicaid Cluster) (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Connected LivingFinding: At Dignity Health Connected Living, internal controls over the required allowability criteria with regard to payroll expense were not performed for 1 of 25 employees selected for testing.Corrective Action Plan: In addition to timecard approval by supervisors, Dignity Health Connected Living finance will review a TEAMs salary report to review that time charged to the grant is accurate and appropriate. Review will be completed on a payperiod basis.Person Responsible: Marcela Ashinhurst, Senior Financial AnalystExpected Completion: April 2023

View Audit 312373

Finding 425672 (2022-013)

Material Weakness 2022

Commonspirit Health

IL

Questioned Costs Allowable Costs / Cost Principles Cash Management

REFERENCE: 2022-013 ? Allowable Costs/Cost PrinciplesCOVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (93.461)Federal Grantor: U.S. Department of Health and Human ServicesFinding Part 1: CommonSpirit Health did not have controls in pla...

REFERENCE: 2022-013 ? Allowable Costs/Cost PrinciplesCOVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (93.461)Federal Grantor: U.S. Department of Health and Human ServicesFinding Part 1: CommonSpirit Health did not have controls in place to limit the claims being submitted for Testing-Related Items and Services to include items and services related to furnishing or administering the COVID-19 test or for the evaluation of such individuals to determine the need for a COVID-19 test.Corrective Action Plan: Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. In addition, Management believes CommonSpirit followed the HRSA uninsured patient reimbursement program guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program.Although CommonSpirit Health continues to dispute the findings (REFERENCE 2021-014), CommonSpirit Health is refunding the Questioned Cost of $10,998 related to the findings for 2021 in order to resolve this finding. The refunds will be completed by April 30, 2023. In addition, the Program stopped accepting claims for testing and treatment on March 22, 2022, and claims for vaccine administration on April 5, 2022, due to lack of sufficient funds. CommonSpirit Health has not submitted claims to the Program since the Program was discontinued. In the event that CommonSpirit Health, through its proactive compliance efforts, identifies any additional claims submitted to the Program where reimbursement may not have been appropriate, CommonSpirit Health will refund such claims.Person Responsible: Danielle Weber, System SVP Revenue CycleExpected Completion: Management believes the item is resolved.Finding Part 2: CommonSpirit Health did not have controls in place to ensure that claims were not submitted for reimbursement when COVID-19 was not the primary diagnosis.Corrective Action Plan: Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. With respect to this one claim where COVID-19 was incorrectly listed in the primary diagnosis position, CommonSpirit Health will refund the claim amount of $547 by April 30, 2023Person Responsible: Danielle Weber, System SVP Revenue CycleExpected Completion: April 30, 2023

View Audit 312373 Questioned Costs: $1

Finding 425611 (2022-014)

Significant Deficiency 2022

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303

REFERENCE: 2022-014 ? Allowable Costs/Cost PrinciplesCoronavirus Relief Fund (21.019)Federal Grantor: U.S. Department of TreasuryFacility: CHI MemorialFinding: At CHI Memorial, controls over the required allowability criteria and period of performance with regard to payroll expense were not performe...

REFERENCE: 2022-014 ? Allowable Costs/Cost PrinciplesCoronavirus Relief Fund (21.019)Federal Grantor: U.S. Department of TreasuryFacility: CHI MemorialFinding: At CHI Memorial, controls over the required allowability criteria and period of performance with regard to payroll expense were not performed and/or documented.Corrective Action Plan: Hospital staff will be provided training to refresh the requirement to approve timecards for supervisees. Accounting/finance will review payroll reports to ensure only time properly approved is charged to grant for reimbursement.Person Responsible: Craig Nielsen, Market Director Operational FinanceExpected Completion: April 2023

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Finding 425603 (2022-010)

Material Weakness 2022

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303

REFERENCE: 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Research and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center did ...

REFERENCE: 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Research and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, the actual hours for all individuals are reviewed. Additionally, a reconciliation of actual to budget is performed. Documentation of the quarterly reviews is maintained on a google shared drive. Quarterly meetings include evaluation of salary charged to grant in comparison to NIH salary cap.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerCompletion: September 2022

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Finding 425602 (2022-008)

Material Weakness 2022

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2022-008 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center used budgeted cos...

REFERENCE: 2022-008 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, the actual hours for all individuals are reviewed. Additionally, a reconciliation of actual to budget is performed. Documentation of the quarterly reviews is maintained on a google shared drive. Clinical time for federal grants will be supported by a completed timesheet signed by a supervisor or PI. Timesheets will be completed monthly.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerExpected Completion: September 2022

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Finding 425601 (2022-009)

Significant Deficiency 2022

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303

REFERENCE: 2022-009 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: At St. Joseph?s Hospital and Medical center, internal cont...

REFERENCE: 2022-009 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Corrective Action Plan: Indirect expense calculation is reviewed and compared to grant agreement by Grant Accounting Manager prior to month end close.Person Responsible: Tomas Cortez, Grant Accounting ManagerCompletion: January 2022

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Finding 424958 (2022-208)

Material Weakness 2022

State of Idaho

ID

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

Finding Number 2022-208: State Opioid Response program performance progress reports did not have documentation to support completion of a review for accuracy and compliance prior to submission.Federal Program: 93.788 - Opioid STRRelated to Prior Finding: N/AAgency?s view: The Department agrees with ...

Finding Number 2022-208: State Opioid Response program performance progress reports did not have documentation to support completion of a review for accuracy and compliance prior to submission.Federal Program: 93.788 - Opioid STRRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.The contract manager attests that she did, in fact, review, edit, re-review and ultimately approve the 5 program performance reports to the grantor. The reports were either emailed to the Program Manager or uploaded in Teams for her review/approval. The auditor was provided documentation of these reviewed documents, including editing notes by that manager. Additionally, one-on-one supervision notes between the person submitting the reports and the contract manager validate that these reports were, in fact, reviewed and approved prior to submission to the grantor. The federal funder does not require this type of documentation of review/approval and the program was not aware of this CFR requirement. The program does, however, agree, that review and approval of these reports was not documented and that a corrective action plan is warranted.Corrective Action: Beginning April 1, 2023, all required federal reports will include thefollowing statement, which will be signed and dated electronically by the approving reviewerbefore the report is submitted:? I, _______________________, have reviewed and approved this report prior tosubmission.Name, titleA copy of the approved and signed report will be retained in DBH?s electronic grant fundingrecords.Anticipated Corrective Action Date: April 1, 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

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Finding 424945 (2022-202)

Material Weakness 2022

State of Idaho

ID

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Finding Number 2022-202: The Commission did not complete required reports for the Federal Funding Accountability and Transparency Act (FFATA).Federal Programs: 93.044, 93.045, 93.053 ? Aging ClusterRelated to Prior Finding: N/AAgency?s view: The Commission agrees with this finding.Corrective Action:...

Finding Number 2022-202: The Commission did not complete required reports for the Federal Funding Accountability and Transparency Act (FFATA).Federal Programs: 93.044, 93.045, 93.053 ? Aging ClusterRelated to Prior Finding: N/AAgency?s view: The Commission agrees with this finding.Corrective Action: Federal Funding Accountability and Transparency Act (FFATA) reporting for federal fiscal years 2021, and 2022 have been completed as of March 27, 2023. The agency will complete FFATA reporting as awards are administered to sub-awardees going forward.Anticipated Corrective Action Date: March 27, 2023Responsible for Corrective Action: Joe Zaher, Senior Financial SpecialistJoe.zaher@aging.idaho.gov 208-577-2864

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Finding 424944 (2022-201)

Material Weakness 2022

State of Idaho

ID

Reporting Allowable Costs / Cost Principles HUD Housing Programs § 200.303

Finding Number 2022-201: The Commission did not complete the required Federal Financial SF-425 Report for the Aging Cluster Grant program in a timely manner.Federal Programs: 93.044, 93.045, 93.053 ? Aging ClusterRelated to Prior Finding: N/AAgency?s view: The Commission agrees with this finding.Cor...

Finding Number 2022-201: The Commission did not complete the required Federal Financial SF-425 Report for the Aging Cluster Grant program in a timely manner.Federal Programs: 93.044, 93.045, 93.053 ? Aging ClusterRelated to Prior Finding: N/AAgency?s view: The Commission agrees with this finding.Corrective Action: Actions have been taken to complete SF-425 reports as they come due for each grant. A reporting workbook has been created to track awards and reporting dates. Reporting period end dates and due dates will be added to fiscal staff calendars. We will continue to keep our federal partners appraised of our progress through completion.Anticipated Corrective Action Date: 'A soft target date for completion of all past due reports is set for September 30, 2023, and a hard target date of December 31, 2023.Responsible for Corrective Action: Joe Zaher, Senior Financial SpecialistJoe.zaher@aging.idaho.gov 208-577-2864

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Finding 424941 (2022-205)

Significant Deficiency 2022

State of Idaho

ID

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding Number 2022-205: An expenditure was made by the Department for unallowable activities from the Elementary and Secondary School Emergency Relief (ESSER) program.Federal Program: 84.425U - Education Stabilization Fund - ARPA ESSER IIIRelated to Prior Finding: N/AAgency?s view: The Department a...

Finding Number 2022-205: An expenditure was made by the Department for unallowable activities from the Elementary and Secondary School Emergency Relief (ESSER) program.Federal Program: 84.425U - Education Stabilization Fund - ARPA ESSER IIIRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.Corrective Action: When the Elementary and Secondary School Emergency Relief Funds {ESSER) were first awarded, it was not required that districts attach any documentation to their Grant Reimbursement Application {GRA) requests. Federal Programs will start requiring that all requests coming in through the GRA system have supporting documentation attached as of July 1, 2023, which is the beginning of our next fiscal cycle.Anticipated Corrective Action Date: We will announce this new procedure through emails and during our state-wide Consolidated Federal and State Grant Application training in April and May2023.Responsible for Corrective Action: Gideon Tolman, Chief Financial Officergtolman@sde.idaho.gov 208-332-6874

View Audit 312368 Questioned Costs: $1

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