Corrective Action Plans

Improper Spending and Monitoring of Coronavirus Relief Fund ActivityState Agency: Governor?s Office of Planning and BudgetFederal Program: Coronavirus Relief FundGOPB will formally document eligibility for Thrive 125 grants and the state?s COVID-19 response dashboard to prepare the state for future reviews by the Department of the Treasury. While closing out the CARES Act CRF grant, GOPB will review expenses allocated for liability insurance to determine if any additional costs should be adjusted to not be charged to the CRF or document if they are appropriately charged as direct costs.Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592Anticipated Correction Date: April 10, 2023

Improper Controls and Monitoring of State and Local Fiscal Recovery Funds ActivityState Agency: Governor?s Office of Planning and BudgetFederal Program: Coronavirus State and Local Fiscal Recovery FundsGOPB will work with all agencies managing SLFRF projects to verify that adequate internal controls have been established to reduce the risk of errors and noncompliance. GOPB will provide a reference guide to agencies to help them develop and implement proper controls over allowable activities and costs. GOPB will update its policies and procedures to sample agency compliance, with a greater focus on agencies that have less experience administering federal funds.To correct the $15.00 of questioned costs made by the courts, GOPB will work with the courts to charge the questoned amount to a different funding source.Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations,801-538-1592Anticipated Correction Date: April 30, 2023

Initial Eligibility Determination Not Documented for 3 SubrecipientsState Agency: Commission on Criminal and Juvenile JusticeFederal Program: Crime Victim AssistanceUOVC management will review standard policy and procedures with its Grant Management Team to provide training and make any necessary adjustments to ensure compliance with subrecipient eligibility determinations. The UOVC Grant Management Team, in alliance with the Federal Fund Financial Manager, will meet to discuss and determine a review process to ensure compliance of documentation.Contact Person: Tallie Viteri, UOVC Asst. Director, Assistance Grant Program Mgr., 801-300-6605Dale Oyler, UOVC VOCA Program Manager, 801-333-3521Moriah Pease, UOVC VAWA & SASP Program Manager, 801-793-8264Anticipated Correction Date: June 30, 2023 (New Grant Awards will take place July 2023)

Program: HOME Investment Partnership Program (HOME)Finding: 2022-001Contact Person: April ApodacaFinancial Services OfficerDevelopment Services DepartmentPhone: (562) 570-6611Email: april.apodaca@longbeach.govPlanned Actions:The Development Services Department (Department) will securely file all HOME monitoring documents and ensure it is accessible to multiple staff. As of June 27, 2023, thirteen of the fifteen non-compliant samples have been secured and communication has been sent to retrieve the remaining two from the developers. The final two samples are due on July 21, 2023, and we fully expect to show compliance documentation by that date. If the documents are not received by the due date, the Department will continue to communicate with the developers by telephone, mail, and email to provide second and third notices. If no response is submitted by the third notice (August 7, 2023) the Department will escalate the matter to the City Attorney?s Office to formally begin taking action for non-compliance

September 14, 2023This is a corrective action plan in response to the audit finding on our FY2022 Single Audit (2022-001) provided to the Town of Rutland on 8/29/2023.Planned Corrective ActionDuring FY2022 and FY2023 there were significant changes to staffing in the Town Administrator and Town Accountants offices. The project to create formalized written policies and procedures that are required under the Uniform Guidance was not completed. The Town has draft policy and procedures established that will be adopted by the Board of Selectmen and will be implemented for fiscal year 2024.Contact person and Completion dateThe Town Administrators office will be facilitating the implementation of the new policy and procedures that will bring us into compliance with the Uniform Guidance for FY2024. The contact information for his office is as follows:Austin Cyganiewicz, Town Admin. ? acyganiewicz@townofrutland.org 508-886-4100 ext. 1000Tomeca Murphy, Executive Asst to TA & BOS ? tmurphy@townofrutland.org 508-886-4100 ext. 2001

GSA_MIGRATION

Finding 2022-002 ? EligibilityA qualified opinion was issued for Assistance Listing 93.011 as the auditors noted that the Corporation expended the full balance of gift cards purchased during the fiscal year 2022 rather than the amount that was distributed to eligible participants. Participants are eligible to participate in the program and receive a gift card if they received a COVID-19 vaccine.Compliance with the eligibility requirements is the responsibility of Kimberly Green Reeves, Executive Director of Community Impact and the grant coordinator. As grants G32HS42634C6 and U3SHS45317C6 ended May 31, 2023, and July 31, 2023, respectively, no further correction action will be taken. However, effective August 15, 2023, if future programs are awarded Beacon Health System (the Corporation) will track the total gift cards purchased as a prepaid expense and expense the gift cards at the time they are distributed to eligible participants. The Corporation Finance will work with the grant administrator to obtain the total amount of gift cards purchased and have that recorded as a prepaid asset. Each month the Corporation Finance will work with the grant administrator to obtain a schedule showing the total amount of gift cards distributed, which will be used to record the appropriate expense each month.

Finding 2022-001 Scope Limitation ? EligibilityA scope limitation qualified opinion was issued for Assistance Listing 10.557 as the auditors were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility. The Corporation uses a paperless system as supported by the State of Indiana and the U.S. Department of Agriculture. Third-party documentation is reviewed by the Corporation at the time the initial eligibility determination of a WIC participant is made. However, due to the paperless system implemented in 2007, these records are not retained. The Corporation?s process for eligibility determination is as follows:1. A (potential) participant comes into the WIC clinic2. A clerk verifies information (by looking and checking the appropriate boxes on the screen)a. Proof of identification (driver?s license, birth certificate, hospital birth record, etc.)b. Proof of residence (bill, lease, driver?s license, etc.)c. Proof of incomei. Working ? 30 days of pay stubsii. Medicaid ? card needed3. All of the above information is entered into the State of Indiana?s systema. System automatically determines eligibilityi. If yes ? they continue with appointmentii. If no ? they get a letter explaining reason why (over income, etc.)Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana?s paperless system as described above, no further corrective action will be taken.

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

STUDENT FINANCIAL ASSISTANCE CLUSTER FINDINGSFINDING 2022-003 - Internal Control over Compliance (Repeat Finding 2021-003, 2020-001, 2019-002, 2018-003, 2017-002, 2015-002, 2014-008)ResponsesNSHE Overall response/context ?NSHE increased its dialogue amongst the three instances of the student information system throughout fiscalyear 2022. The results of this robust dialogue led to additional controls to reduce related IT risks, enhancedmonitoring of activities, and targeted periodic reviews, highlighted in each instance?s response below. Theseenhanced techniques operating throughout the entire fiscal year ahead, should provide a stronger overall controlenvironment and lower associated risks.UNR ?? Detailed corrective action taken, including what will be done to avoid the identified issues inthe future, and when these measures will be in place;UNR has implemented controls to address the risk associated with the PeopleSoft Administrators(PSA?s) access to the production and development environments. The controls include:1. The University will remove the PSA role for the three individuals that are identified as not havingthe appropriate segregation of duties. The PSA role is still required of the University and will onlybe granted on a temporary basis when necessary and this access will be, documented, monitored,and deactivated upon completion of the required tasks.a) Approvals ? A PSA role is granted for task specific business needs and when the individualssecurity level does not permit the action to be performed. When justified, the PSA role isgranted by a security administrator.b) Documented ? When the PSA role is granted a notification is triggered to the Associate VicePresident, Planning, Budget and Analysis, the Registrar and the Director of AccountingOperations as to the role assignment and the person assigned.c) Monitored ? The activities performed are documented and monitored in a TeamDynamixticket.d) Deactivated ? The PSA system access is deactivated upon completion of the required activity.The deactivation is documented in the TeamDynamix ticketing system.2. The University will implement a quarterly User Access Review that identifies the incidences ofwhen the PSA role is granted and when the PSA login occurs and compares this to Team Dynamixto establish the activity. The activity can be compared to the system for validity. This will beperformed by the Registrar. 3. The University will continue to explore and research Change Control Systems as options tomonitor activities of the PSA?s.? How compliance and performance will be measured and documented for future audit,management and performance review.The PSA role will not be established for continuous periods of time. When the PSA role is temporarilygranted it is documented and tracked in Team Dynamix. This provides an audit trail of role access,timeframes of logins, and activities.? Who will be responsible and may be held accountable in the future if repeat or similarobservations are noted.The Associate Vice President, Planning, Budget and Analysis will monitor the compliance with thecorrective action plans and will implement new processes as needed to meet the needs of mitigatingthis risk and the system updates and changes.UNLV ?UNLV agrees with this finding.? Detailed corrective action taken, including what will be done to avoid the identified issues inthe future, and when these measures will be in place;UNLV understands the importance of adequate segregation of duties within the PeopleSoftenvironments and applications. The PeopleSoft Administrator (PSA) position that is the subject ofthe finding is responsible for the installation, configuration, upgrades, and troubleshooting of all theapplication environments. The PeopleSoft Administrators are not programmers/developers, andtheir access to the production environments is periodically required to perform the needed activitiesrequired to provide timely support of the application within the scope of their job duties.UNLV has implemented the following controls to mitigate the risks associated with the elevatedaccess required for the administrators to perform their required support activities.a. UNLV will remove the PeopleSoft Administrator role from all PSAs in productionenvironments.b. The PeopleSoft Administrator role will be assigned temporarily when elevated actions arerequired. The assignment will have the following requirements:i. Be limited in duration.ii. Document a justification detailing the need and actions to be performed.iii. Generate notification to the Director of Enterprise Applications.iv. Automatically be removed.v. It is reviewed as part of normal audit activities. c. UNLV will increase their reviews of access, activities, and assigned privileges to monthly forthe PeopleSoft Administrators.d. UNLV will continue researching and implementing other control methods to address thesegregation of duties while providing appropriate service and support.? How compliance and performance will be measured and documented for future audit,management and performance review.The PeopleSoft Administrator role will no longer be a persistent assignment to the PSA position.UNLV will perform monthly reviews of the access and activities to determine if the PeopleSoftAdministrators' current levels require further refinement. Additionally, UNLV will continue toresearch other control methods that will address the segregation of duties while providingappropriate service and support.? Who will be responsible and may be held accountable in the future if repeat or similarobservations are noted.The Director of Enterprise Applications will be responsible for reviewing the access needs of thePeopleSoft Administrators. The Director will complete the reviews and is also accountable if repeat orsimilar observations are noted. The Chief Information Security Officer will verify the reviews are permonthly audit practices.SCS ?? Detailed corrective action taken, including what will be done to avoid the identified issues inthe future, and when these measures will be in place;PeopleSoft Administrator (PSA) access to the Production and Development environments arereviewed on an ongoing basis. Due to the need to develop and perform program changes for all fiveshared-instance Institutions on a frequent basis it was determined that PSA access cannot be reducedany further. However, to address the segregation of duties risk the following compensating controlsare in place:(a) STAT for PeopleSoft ? Code control and internal modification tracking provides visibility over PSAactivities that are processed via this tool. These object changes are reviewed and approved by theDirector of Information and Application Services.(b) JIRA - Change control management and project tracking software. Change requests and projectsrelated to the PeopleSoft shared instance are tracked and approved. This would include user accessmodifications and system updates for example.(c) Security e-mail alerts ? The SCS security team are alerted via automated e-mails when user access(to include PSA roles) is changed.(d) User Access Reviews ? On an annual basis a user access review is performed incorporatingSCS/SA privileged users and all shared instance security coordinators SCS will implement the following additional control from FY22/23 going forward:(e) Splunk reporting and monitoring ? Reporting and trigger events developed incorporating PSAactivity ?anomalies?. For example, PSA after-hour logins reviewed and matched to plannedupdates/activities.(f) Periodic management reviews ? A formal review incorporating, and documenting PSA andassociated exception activities will take place. Where appropriate this will include approvals anddocumented rationale.SCS will continue to explore additional solutions to minimize the segregation of duties risk, especiallyas it relates to the monitoring of PSA activities.? How compliance and performance will be measured and documented for future audit,management and performance review.The periodic management review where appropriate will include documentation and approvals tosupport PSA activities that do not meet established criteria. This review will also document anyfollow-ups required as it relates to similar controls. For example, security e-mail alerts.? Who will be responsible and may be held accountable in the future if repeat or similarobservations are noted.SCS Director of Information and Application Services, SCS Security Group.

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 13, 2023, regarding a reportable audit finding related to Inadequate Controls over Eligibility Determinations. LDH appreciates the opportunity to provide this response to your office's findings.Finding: Inadequate Internal Controls over Eligibility DeterminationsRecommendation: LDH should ensure its employees follow procedures relating to eligibility determinations and redeterminations in the Medicaid and CHIP programs to ensure the case records support the eligibility decisions.LDH Response: LDH does not concur with this finding.The audit period occurred during the COVID-19 Public Health Emergency (PHE). The federal Centers for Medicare & Medicaid Services (CMS) which has oversight of the Medicaid and CHIP programs has issued a number of guidance documents which set forth and at times changed actions and steps States should be taking to comply with the FFRCA continuous eligibility provision as well as preparing for the end of the PHE. Program decisions that affected normal policy and procedures were made based on guidance at that particular time while also being cautious to not jeopardize enhanced federal matching funds under the FFRCA by inappropriately terminating an individual's coverage during the PHE.Audit staff indicated three instances of Medicaid and two instances of CHIP beneficiaries not having renewals performed and documented per the Medicaid eligibility manual.LDH notified audit staff it was still operating under a March 25, 2020 approved waiver from CMS on certain flexibilities in meeting the timeliness of Medicaid renewals in accordance with 42 CFR ? 435.912(e)(2). CMS' approval stated, in part:Louisiana has indicated that the agency expects that it will be unable to meet timeliness requirements for processing applications, completing renewals and acting on changes in circumstances through the duration of the emergency. We understand that to prevent coverage from being terminated inappropriately if Louisiana is unable to complete renewals timely, the agency may need to set a future renewal date in the eligibility system. Federal regulation at 42 CFR 435.912(f) requires the agency to document the reason for delay in each applicant's and beneficiary's case record.LDH, as did other states, used this flexibility to suspend renewals during the PHE. LDH continued to try and process renewals through an ex parte basis and only suspended those that would require requesting information from beneficiaries. While there was no particular documentation in the "case note" section of the Louisiana Medicaid Eligibility Determination System (LaMEDS), LDH provided audit staff with LaMEDS log tables which documented system jobs called "data fixes" that were completed which set certain renewals to a future date per the approved flexibility. LDH continues to firmly believe the "case record" contemplated in CFR 435.912(f) includes all aspects of data repositories or system actions in the case, along with text fields in the case notes and the documents in the LDH document management system. In accordance with 42 CFR 433.112(b) and 45 CFR 164.312(b), LaMEDS logs system activity and enables the State to examine and document system actions.Audit staff cited one instance of coverage that was not discontinued on a beneficiary invalidly enrolled prior to the start of the PHE. LDH staff did not timely act on a task to terminate coverage for this beneficiary prior to the beginning of the PHE in March 2020. Under the continuous eligibility provision of the FFCRA of 2020, a state could not terminate individuals from Medicaid if such individuals were enrolled in the program as of the date of the beginning of the emergency period, unless the individual voluntarily terminates eligibility or is no longer a resident of the state. No exceptions were noted for delays in taking negative action, therefore, when LDH staff tried to process the termination in April 2020, system implemented restrictions for the continuous enrollment provision prevented it.In November 2020, CMS issued an Interim Final Rule (CMS-9912-IFC) which provided additional information concerning the continuous enrollment period and allowable terminations and transitions during the PHE. The Interim Final Rule clarified that states may terminate coverage prior to the end of the PHE for beneficiaries not validly enrolled. Defined at 42 CFR 433.400, a beneficiary is not validly enrolled if the agency determines that the determination of eligibility was incorrect at the most recent determination, redetermination, or renewal of eligibility because of agency error or fraud. CMS guidance for the Interim Final Rule issued as an update to the Frequently Asked Questions (FAQ) for the continuous enrollment section of the FFRCA indicated that "as of November 2, 2020, references to "coverage" in this FAQ should be read as "enrollment" and the continuous enrollment condition should be applied only to "validly enrolled" beneficiaries as defined at? 433.400(a)." The Interim Final Rule nor the FAQ guidance that followed provided any instruction to review or take action on cases that were prevented from terminating prior to its release. LDH applied the clarification of "validly enrolled" on decisions going forward therefore the beneficiary's coverage remained open.LDH did agree with Audit staff in the one instance where the beneficiary was not terminated for moving out of state. Established procedures were not followed to confirm the out of state address and terminate coverage appropriately.With the explanation provided to audit staff during their review and repeated here, LDH does not agree there was a lack of internal controls over eligibility determinations that warrant a finding.You may contact Tara A. Leblanc, Medicaid Executive Director at (225) 219-7810 or via e-mail at Tara.LeBlanc@la.gov or Rhett Decoteau, Medicaid Section Chief at (225) 342- 9044 or via email at Rhett.Decoteau@la.gov with any questions about this matter.

Dear Mr. Waguespack:The Louisiana Department of Education (LDOE) appreciates the opportunity to submit an official response to the audit finding entitled: Weakness in Controls over Child Care Development Fund Grants. The LDOE concurs in part with the finding. The LDOE was aware of the risks of distributing this large amount of funds while using systems not made for these purposes, and therefore, put in place specific additional controls to enhance the LDOE?s existing recoupment and fraud processes which are designed to control and capture these situations.Issue 1: LDOE overpaid six child care providers who received ARPA Child Care Stabilization funds by a total of $59,063. The LDOE is conducting final reviews and assessments for the ARPA Round 1 and 2 grants and firmly believes these overpayments would have also been captured during this audit process. The amount of funds classified as overpayments for this issue represents 0.01% of funds distributed. The LDOE has already recouped funds from five of the six providers associated with these overpayments through existing processes. The LDOE will clarify and/or amend existing procedures to include enhanced evaluation of grant distribution calculations for all future work. In addition, the LDOE will also return to previously processed issues and evaluate all grant distribution calculations.Issue 2: During LDOE?s review of payments to child care providers who received grant payments funded with CRRSA and ARPA funds, LDOE identified overpayments to 11 child care providers totaling $887,212. LDOE has represented that they recover. The LDOE has recouped 96% of the funds from overpayment and continues the work necessary to recoup the remaining amount. In response to the payment errors experienced with prior grants, the LDOE has begun executing test runs in the system to allow us to review the award amount compared to the payment amount prior to the actual payment. Additionally, LDOE is working to identify additional controls to capture possible errors early in the process.The Child Care and Development Fund (CCDF) is the primary federal funding source for child care subsidies to help eligible low-income working families access child care and improve child care for all children. The CARES Act, Coronavirus Response and Relief Supplemental Appropriations Act, and the ARP Act appropriated additional supplemental CCDF Discretionary funds. This funding was to provide Lead Agencies with additional funds to prevent, prepare for, and respond to the Coronavirus Disease 2019 (COVID-19), and expand flexibility to provide child care assistance to families and children. The Administration for Children and Families, Office of Child Care strongly encouraged Lead Agencies to quickly get funds to child care providers in order to stabilize the industry and ensure child care for families.In order to provide support to the child care providers of Louisiana as soon as possible, the LDOE opened the application period for the first stabilization grant in a very short time period. Since the first grant, the LDOE has received and processed over 10,500 grant applications and distributed approximately $497 million dollars to child care providers to meet the intent of the law.Thank you for the opportunity to respond to this issue. Kim Nesmith, Director of Early Child Care and Education Administrative Affairs and Child Care and Development Fund Administrator, will be the contact person responsible for corrective action that will be completed by June 30, 2023. The LDOE is committed to implementing the necessary procedures to improve these processes.

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 27, 2023, regarding a reportable audit finding related to Noncompliance with Provider Revalidation and Screening Requirements. LDH appreciates the opportunity to provide this response to your office?s findings.Finding: Noncompliance with Provider Revalidation and Screening Requirements.Recommendation: LDH should ensure all providers are screened based on categorical risk level upon initial enrollment, re-enrollment, and revalidation of enrollment as required by federal regulations. Also, LDH should perform revalidation of enrollment on all providers at least every five years. In addition, LDH should ensure all required databases are checked at least on a frequency required by federal regulations.LDH Response:LDH partially concurs with your finding that it did not perform five-year revalidations. Louisiana is actively working on compliance with this requirement which is detailed in the corrective action plan.Corrective Actions:LDH amended the Gainwell contract to accomplish provider revalidations, with CMS- approved funding in Amendments 20 and 21 dated January 2021. Since the launch of the online Provider Enrollment Portal, 39,151 Fee-For-Service (FFS) and Managed Care Organization (MCO) providers have successfully completed or submitted their enrollment applications.Gainwell, on behalf of LDH, is performing monthly monitoring on Enrollment Complete (EC) provider portal records against OIG-LEIE, CMS Medicare Exclusion Database (MED) and SAM databases. Gainwell checks these databases on all FFS providers at the time of new enrollment, re-enrollment, or a change of ownership including OIG exclusions. Gainwell has performed categorical risk-level scoring for FFS providers upon initial enrollment for several years. All FFS revalidations which includes screening and risk-based scoring, are performed using the Provider Enrollment Portal which commenced on July 1, 2021. Monthly monitoring for the Provider Enrollment Portal project, which includes categorical risk level scoring for initial enrollment, re-enrollment and revalidations, is being conducted on all MCO and FFS providers.The LDH Program Integrity Section began performing monthly checks of the SAM database on FFS providers not yet revalidated or newly enrolled in March 2022.LDH and Gainwell continue to make enhancements to the portal and processes to become fully compliant.You may contact Tara A. Leblanc, Medicaid Director at (225) 219-7810 or via e-mail at Tara.LeBlanc@la.gov or Brandon Bueche, Medicaid Section Chief at (225) 384-0460 or via email at Brandon.Bueche@la.gov with any questions about this matter.

Dear Mr. Waguespack:The Louisiana Workforce Commission (LWC) respectfully submits its response to the finding Inadequate Controls and Noncompliance with Unemployment Insurance Benefits Requirements, included in the Single Audit Report.The LWC vehemently disagrees with the LLA?s interpretation of federal ?wage documentation? and identity verification requirements. Assuming arguendo the LLA actually meant ?proof of employment? rather than ?wage documentation?, any determination or finding of a failure to provide proof of employment is premature absent a request to provide such proof and absent USDOL disposition of the State?s blanket waiver request. As stated in the report, LWC issued more than $681 million in benefit payments to more than 260,000 claimants during Fiscal Year 2022. The questioned costs of $30,704, however, account for less than 0.005 percent of total benefits paid.It should be noted that all of the purported ?errors? identified in the report occurred under the hastily assembled Pandemic Unemployment Assistance (PUA) program. The implementing legislation (CARES ACT) and initial USDOL guidance for implementation of the PUA program expressly prohibited states from verifying employment and wages, establishing PUA as a self- attestation program. States were inundated with claims that, when taken at face value, appeared to qualify for benefits. It was only after widespread fraudulent activity and rampant abuse of the self-attestation legal requirement that Congress later implemented identification, employment, and wage verification requirements to be completed either during the application process or retroactively. The program requirements were ever-evolving and amended to address situations and deficiencies that all states encountered. Many states are still working to implement this retroactive guidance provided by USDOL.Although our State ended pandemic programs in July 2021, we continue to work through a substantial backlog of pandemic cases, a backlog that is a direct result of the PUA program?s initial lax requirements. What is more, in August of 2021, less than one month after the pandemic programs ended, the state faced its sixth declared disaster in a two-year period, and the LWC was immediately tasked with administering Disaster Unemployment Assistance for yet another major disaster. The LWC responded to the Pandemic and the multiple disasters that impacted the state as effectively as possible. Our Agency will continue to work diligently to resolve the issues noted in the report and to investigate claims to determine proper eligibility.Should you have any questions or need additional information, please feel free to contact my office at 225-342-3001.Inadequate Internal Controls and Noncompliance with Unemployment Insurance Benefit RequirementsThe Louisiana Workforce Commission (LWC) concurs in part. As stated in our response to the same finding last year, it was nearly impossible to implement adequate internal controls and ensure full compliance with the pandemic programs given little time, insufficient guidance, and inadequate resources to implement not only the initial requirements, but later burdensome retroactive requirements all while managing a record-breaking surge in claims volume.Wage Documentation RequirementsIn all cases cited in this report, the ?wage documentation? the auditor was expecting to see is what is referred to as ?proof of employment.? This finding refers to a retroactive requirement that was put in place with the Continued Assistance Act (CAA) and requires the Agency to provide notice to individuals, who filed for PUA before enactment of this requirement, to provide proof of employment within 90 days ?all after previously notifying them that proof of employment was not a requirement of the program. Failure on the part of the individual to provide proof of employment would result in a retroactive disqualification back to December 27, 2020, thus causing a substantial overpayment. The 90-day timeframe does not commence until an official request is transmitted to the individual.The documentation was not on file for the cases in question because the LWC has not yet requested this information from individuals subject to the 90-day proof of employment requirement. Not only was there a ?unique confluence of circumstances? that prevented the LWC from sending out these notices in a timely fashion, but we strongly believe that any overpayments resulting from a claimant?s non-compliance with this requirement is through no fault of their own. To that end, last year, the LWC requested a blanket waiver of overpayments resulting from implementation of this requirement. USDOL ETA?s response to this request will dictate how we proceed with implementation of this requirement. The blanket waiver allowance would only slightly minimize the burden and confusion that implementation of this retroactive requirement causes.Missing IdentificationThe LWC agreed to disagree with the LLA?s interpretation of the identity verification requirements set forth in the CAA. Unemployment Insurance Program Letter 16-20, change 4 provided the following guidance:Requirement to Verify Identity. Section 242 of the Continued Assistance Act requires that states must include procedures for identity verification or validation for timely payment, to the extent reasonable and practicable, by January 26, 2021 (30 days after the enactment of the Continued Assistance Act) to ensure that they have an adequate system for administering the PUA program. Refer to section C.3. of Attachment I to this UIPL for additional details. [Emphasis supplied.]Section C.3:Verification of Identity (Section 242(a) of the Continued Assistance Act) (new). Section 242(a) of Continued Assistance Act modifies Section 2102(f)(1) of the CARES Act. For states to have an adequate system for administering the PUA program, states must include procedures for ?identity verification or validation and for timely payment, to the extent reasonable and practicable? by January 26, 2021, which is 30 days after December 27, 2020 (enactment of the Continued Assistance Act). States that previously verified an individual?s identity on a UC, EB, or PEUC claim within the last 12 months are not required to re-verify identity on the PUA claim, though the Department encourages the state to take additional measures if the identity is questioned. Individuals filing new PUA initial claims that have not been through the state?s identity verification process must have their identities verified to be eligible. The Department strongly encourages states to use the Identity Verification (IDV) solution offered by the UI Integrity Center as part of its Integrity Data Hub (IDH) as one method to meet this requirement. This IDV solution offers states advanced fraud risk scoring to I-13 maximize front-end ID verification, aiding states in assessing whether an individual is using a false, stolen, or synthetic ID. It is available to states at no cost and is a secure, robust, centralized, multi-state data system that allows participating state UI agencies to submit claims for cross matching and analysis to support the prevention and detection of improper payments, fraud, and ID theft. There is also a range of other tools on the market that states may consider to satisfy this requirement for identity verification. States are also strongly encouraged to explore implementation of complementary and rigorous forms of identity verification solutions. The Department will provide states with additional administrative funding to support state costs to implement PUA identity verification processes and solutions and to continue work to address fraud in both the PUA and PEUC programs.[Emphasis supplied.]In the above guidance, we see two requirements (i.e., ?states must?) for our system to be considered ?adequate? for the purpose of administering the PUA program. First, we must have identity verification or validation procedures in place, to the extent reasonable and practicable, by January 26, 2021. In order to thwart the surge of fraudulent claim activity, the LWC implemented identity verification procedures in November 2020 and going forward for all new claims filed, including all new PUA claims. Additionally, we implemented identity verification procedures for anyone whose claim was flagged for suspicious indicators that called into question the individual?s identity. These procedural safeguards were in place even before November 2020. Second, we must verify identities for all individuals filing new PUA initial claims.In the four cases cited in this report, all were PUA initial claims filed long before the CAA identity verification requirements were enacted, and none had been flagged for staff?s review based on suspicious indicators that called the claimant?s identity into question. It would not have been ?reasonable or practicable? for us to verify identities on every single PUA claim filed since the beginning of the Pandemic. The workload the new identity verification requirement created was already more than existing staff and system resources could timely handle.Child Support DeductionsThe child support payments were not properly withheld in the case cited on the report due to a one-off staff training issue. Staff closed the child support work item with no action taken in error, believing the claim was monetarily ineligible. The staff person overlooked that there was an existing PUA claim on file.Contact Person: Margaret MabileCorrective Action Plan: The LWC will continue to work through the pandemic backlog and address issues as they arise.Anticipate Completion Date: Ongoing

Dear Mr. Waguespack:The Division of Administration, Louisiana Office of Community Development (LOCD) is submitting the following in response to the audit finding titled "Restore Louisiana Homeowner Assistance Program Awards Identified for Grant Recovery."LOCD acknowledges the LLA finding of "Restore Homeowner awards identified for Grant Recovery. " In response to the 2016 Floods, the LOCD created the Restore Louisiana Homeowner Assistance Program (HAP). Grant recapture procedures were established from the beginning of the program and have been implemented timely. It is impossible to administer a disaster recovery program that will not have certain files requiring grant recapture during the life of the program. The Restore Program requires a duplication of benefits check on all files prior to grant execution. For example, it is always possible an applicant may receive additional funding, e.g., insurance proceeds that are deemed duplicative by law. The Restore Program has controls in place to capture these amounts in the grants management system, subrogation agreements executed with each applicant, and recapture procedures to recover the funds. From the very beginning, the Restore Program was created to minimize the potential of applicants' ending up in recapture. As a result, the state has issued over $670 million to 17,262 homeowners of which 80, or 0.46% have been placed in recapture. As the Restore Homeowner Program comes to a close, LOCD does not anticipate further files requiring recapture of funds.LOCD agrees with the observation of 8 files with a potential grant recapture as a necessary ongoing activity for the Program. LOCD will continue to follow the established recapture procedures for these grant awards to ensure ultimate compliance, however, this is not a corrective action, but rather the continued implementation of program protocols.The contact person responsible for these ongoing compliance activities is Ginger Moses, OCD Chief Operating Officer. The anticipated completion date for activities addressing this finding will coincide with the closing of the Restore Louisiana program.If you have questions or require additional information, please feel free to contact me.

Dear Mr. Waguespack:The Division of Administration, Louisiana Office of Community Development (OCD) submits the following in response to the audit finding titled "Inadequate Recovery of Small Rental Property Program Loans."The Small Rental Property Program (SRPP) has two tiers of compliance obligations. The federal compliance requirements are for the CDBG funds issued to a borrower to meet a National Objective and be expended on an Eligible Activity. On top of the federal requirements, the State has its own program requirements. Upon the initial placement of an eligible tenant in a habitable unit at a restricted rent amount, the U.S. Department of Housing and Urban Development (HUD) requirements have been satisfied. Most of the matters made the subject of your report deal with the borrower's non-compliance with the State's program rules, not the HUD requirements.OCD has allocated approximately $649 million to the SRPP program to fund approximately 4,500 applicants and we maintain an ongoing monitoring process to promote compliance and continued availability of affordable housing. Consistent with the program's mission of preserving and expanding much needed affordable housing, OCD's primary focus for the SRPP is to assist property owners in achieving and maintaining compliance, i.e., creating and continuing affordable housing opportunities, as opposed to foreclosure and/or recapture of funds, and are, therefore, not subject to recapture by HUD.In summary, as of June 30, 2022, the LLA reports that 1,156 applicant files have been identified as noncompliant. Of these, 163 files have been determined to be uncollectible, leaving 993 files that are actively being addressed. OCD's compliance and repayment efforts relating to the state imposed continuing requirements of the program are ongoing. See corrective action plan for footnote. The optimal outcome of these efforts is the continued availability of affordable housing through compliance.In June 2016, OCD, working with the Louisiana Housing Corporation (LHC) and HUD, identified 397 SRPP borrowers that did not meet a National Objective. Immediately thereafter, OCD's Legal Section and LHC program staff began communicating with non-compliant borrowers and evaluating proposed workouts. OCD sent default letters to and initiated recapture efforts on all borrowers. Each file is processed with a goal of either achieving compliance, securing repayment, or identifying another viable workout plan. As of June 30, 2022, of the 397 files identified, 76 borrowers have become compliant, 14 have either partially or fully repaid their loans, 18 borrowers have transferred their housing obligations to other compliant properties and 28 have been determined uncollectable for various reasons. As noted in the audit, OCD continues to seek technical assistance regarding the enforcement of mortgages through the judicial foreclosure/public auction process.In conclusion, OCD will continue the efforts to recover those loans determined to be ineligible in accordance with policies and procedures that are acceptable to HUD. Concurrently, OCD will also continue to assist rental property owners to become compliant and to resolve any program compliance issues, thus increasing available affordable rental housing and reducing or eliminating the need to recapture funds from rental property owners, where appropriate.The contact person responsible for the corrective action is Ginger Moses, OCD Chief Operating Officer. Once approved by HUD, the anticipated completion date for this corrective action plan will coincide with the closing of the SRPP program.If you have questions or require additional information, please feel free to contact me.

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.

REFERENCE: 2022-006 ? EligibilityHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoSt. Mary Medical Center ? Long BeachFinding: St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did notconsistently retain evidence of their internal controls over the requirement to review eligibility requirements prior toadministering services in accordance with the grant agreements.Corrective Action Plan: This finding has been corrected. The 6 month eligibility check is no longer required. Forthe annual eligibility checks at St. Mary?s Medical Center ? San Francisco, all HIV patients are listed on an Excelspreadsheet that is on a shared drive. Both the Social Worker and Case Manager are responsible for monitoring andupdating patient information contained on the spreadsheet. The spreadsheet is monitored and updated daily. Hardcopies of eligibility documents are kept in a locked file cabinet located in the Social Worker?s office. Along with thehard copies, a face sheet listing eligibility documents, patient name and medical record number and name of personwho received the documents is documented. Electronic copies of eligibility documents are kept on the CaseManager?s password protected computer hard drive. The disposition and status of each patient is documented on thespreadsheet. The date documents were last collected is listed in the first column on the eligibility spreadsheet.Patients not participating on the ADAP program are contacted at least 15 days prior to the expiration of eligibilitydocuments on file. Patient contact attempts are documented in the patient?s medical record. In the event the patientdoes not respond to phone calls the patient is sent a certified letter. Patients may be contacted via secure email withthe address on file. The spreadsheet is reviewed weekly. Outreach attempts are documented in the patient?smedical chart. Corrective action was implemented in July 2022.At St. Mary Medical Center ? Long Beach, In April 2022 management implemented a more robust and electronicfile for each client to make it easy to ensure appropriate tracking of eligibility requirements validation. Files arereviewed monthly to ensure compliance.Person Responsible: Toni Luckett, Manager of Nursing, St. Mary?s San FranciscoSharon McNealy, CFO ? St. Mary Long BeachCompletion: April 30, 2022

REFERENCE: 2022-012 ? EligibilityMedicaid Cluster (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Medical FoundationDignity Health Connected LivingFinding: The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided.Corrective Action Plan: For the Medical Assistance Program eligibility is validated through a Medi-Cal system website. Dignity Health Medical Foundation personnel have implemented procedures to ensure documentation of eligibility checks are retained. The Clinic Operations manager has instructed staff and supervisors to save proof of eligibility for all months. The Clinic Operations manager checks for retention of eligibility documentation on a random basis and an internal audit will be performed to check for compliance with the documentation retention.At Connected Living the staff will identify participants who may be ineligible for continued services at the beginning of each service month. The Medi-Cal eligibility report is produced on the first business day of each month. The list includes all eligible and ineligible participants. This report will be saved each month for tracking purposes. The report will be reviewed each month for ineligible participants or factors that may impact eligibility for the coming month. Steps will be taken to obtain proof of eligibility or being termination proceedings.Person Responsible: Nicole Hill, Clinic Operations Manager, Dignity Health Medical Foundation.Kristina Devan, Dignity Health Connected LivingCompletion: July 1, 2022

California: Recommendation: We recommend the Institute review its policies and procedures around sending entrance and exit counseling information to students to ensure students are receiving proper counseling and ensure entrance counseling is documented before loans disbursements are made.Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A process in banner is run to catch any new students that need RRAAREQ updates with exit counseling. This will get students who have withdrawn, less than 1/2-time attendance, not enrolled, graduated or schedule to graduate. Once the requirement is on the account, then another process is run to get all of the students with the EXIT code still outstanding and send an e-mail to campus and personal e-mail. Students will receive emails every 30 days to complete the requirement until it is satisfied.Name(s) of the contact person(s) responsible for corrective action: Financial Aid Office, California, Clarion and Edinboro- Kelly Vitelli, Sue Bloom or Traci NecciaiPlanned completion date for corrective action plan: Plan is currently being employed.

Finding: 2022-056 - Certain behavioral health providers were not screened and enrolled in accordance with federal eligibility requirements.Questioned Costs: Assistance Listing 93.767: $1,669; Assistance Listing 93.778: $425,224Assistance Listing Number: 93.767; 93.775, 93.777, 93 .778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The department is assessing the issues identified in the fmdmg and collaborating internally on the necessary corrective action. It is anticipated multiple courses of action may be necessary and include, among others, strengthening the provider enrollment grid and policies.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2025.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-055 - Seven of 30 (23 percent) Medicaid eligibility cases and two of 20 (10 percent) CHIP eligibility cases tested were sent written eligibility notices that contained inconsistent or incorrect information regarding the eligibility period and application date.Questioned Costs: NoneAssistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) continues to strengthen online staff development and training offerings available in the department?s electronic training portal which include courses on MAGIICHIP Medicaid and ARIES. The agency continues to streamline the Statewide Case Review Team and the case review guidelines reflecting the team?s requirement to spend 80 percent of their time reviewing cases with the goal of increasing timeliness and accuracy. A contractor was secured to serve as the primary resource in addressing Alaska Resource for Integrated Eligibility Services (ARIES) system defects and is assisting in the system?s maintenance and operations. The contractor started defect resolution activities and pushed the first round of defect fixes (Release) into the ARIES Production Environment, 7/8/2022. Defect resolution is an ongoing activity, the Contractor will continue to review and fix existing, as well as any new defects encountered. Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-052 - An examination of the Alaska Resource for Integrated Eligibility Services system during FY 22 identified significant intemal control deficiencies.Questioned Costs: NoneAssistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): A contractor was secured to serve as the primary resource in addressing Alaska Resource for Integrated Eligibility Services (ARIES) system defects and is assisting in the system?s maintenance and operations. The contractor started defect resolution activities and pushed the first round of defect fixes (Release) into the ARIES Production Environment, 7/8/2022. Defect resolution is an ongoing activity, the Contractor will continue to review and fix existing, as well as any new defects encountered.Completion Date (list anticipated completion date): The audit finding was fixed in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-054 - Thirty Medicaid and 20 CHIP recipients with paid medical claims during FY 22 were randomly selected for eligibility testing. Auditors found inaccurate or unsupported eligibility determinations by DPA staff for 33 percent of Medicaid cases tested and 10 percent of CHIP cases tested.Questioned Costs: Assistance Listing 93.767: $20,115; Assistance Listing 93.778: $16,945Assistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DHSS concurs with the finding but not the questioned costs. CMS has notified the state that financial recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS? Payment Error Rate Measurement (PERM) program, under section 1903(u) of the Social Security Act and regulations at 42 CFR Part 431, Subpart Q.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) continues to strengthen online staff development and training offerings available in the department?s electronic training portal which include courses on MAGI/CHIP Medicaid and ARIES. The agency continues to streamline the Statewide Case Review Team and the case review guidelines reflecting the team?s requirement to spend 80 percent of their time reviewing cases with the goal of increasing timeliness and accuracy.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

Finding: 2022-053 - Thirty Medicaid and 20 CHIP recipients with paid medical claims during FY 22 were randomly selected for eligibility testing. Auditors found DPA staff did not process applications in a timely manner or redetermine eligibility when required for 87 percent of Medicaid cases and 90 percent of CHIP cases tested.Questioned Costs: NoneAssistance Listing Number: 93.767; 93.775, 93.777, 93.778Assistance Listing Title: CHIP; Medicaid ClusterViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding.Corrective Action (corrective action planned): The Division of Public Assistance (DPA) continues to streamline internal processes, including staff training on the use of the electronic document management system (ILINX) and the Instant Eligibility Verification System (IEVS) to increase accurate and timely eligibility renewals. The department also completed a procurement during FY22 to secure a contractor, who is serving as the primary resource in implementing an automated renewal process. The contract became effective 03/01/2022.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner