Corrective Action Plans

Finding: 2022-006Name of contact person: Felissa H. Ferrell, Cathy MurrayCorrective Action: "The functionality of the system does not connect the child to the other siblings when the 5120 is keyed in the NC FAST System. When the social worker keys in the relationships of the family members in the household, they establish each parent and child, however, the system does not connect the sibling to the other siblings. If a paper 5120 were to be utilized, this would not be an issue. Apparently, with the recent NC FAST System updates, in order for all the siblings to show up on the 5120, it will now require the worker to establish the children to parent, then they will have to establish a relationship to each sibling and/or other members in the household, connecting them all together. This will require additonal data entries. It appears the system was intuitively doing this when connected with the EB NC FAST system however, the upgrades and separation has now made this not function.The Quality Assurance Social Work Specialist will commence a training with the supervisors and CPS workers, who complete the 5120, to ensure the staff understand the extra steps they are required to complete in the NC FAST system. The Quality Assurance Social Work Specialist will review the 5120s to ensure that the FAU is populating correctly. If the additional steps do not show the 5120 populating correctly, then a NC FAST Help Ticket will be generated, likely a level 3, which will require a patch. "Proposed Completion Date: Training will be completed by October 28th, 2022

Assistance Listings number and program name: 21.023 COVID-19 Emergency Rental Assistance ProgramDepartment: Maricopa County Human ServicesContact Person(s): Nicole Forbes, Finance Manager, Human Services Department.Anticipated completion date: June 30, 2023Concur: The Maricopa County Human Services Department (HSD) concurs that the payments noted by the Office of the Auditor General had suspicious activity. The payments noted represent less than .06% of Emergency Rental Assistance (ERA) financial transactions that the County processed in fiscal year 2022. In FY 2022, the HSD provided nearly $75.8 million in rental assistance, which equated to 9,940 financial transactions and 63,265 months of rental assistance for households living in Maricopa County. To help mitigate control discrepancies, the County has continued to strengthen internal controls from the inception of the ERA program. In July-September 2021, HSD implemented review of property information on the Maricopa County Assessor?s website for certain rental assistance applications on a case-by-case basis. However, HSD did not document those reviews or implement the review program-wide until September 2022. In September 2022, HSD updated internal controls through a revision of the ERA policy and process manual to require property information to be reviewed and also documented. In addition, in November 2022, the County worked with our banking institution to implement additional bank verification controls to more accurately and timely verify vendor banking information to further ensure payments were being sent to the approved landlord/property/manager/vendor. The County will continue with these internal controls to ensure accurate payments are processed.

FINDING # 2022-0232021-0202020-0072019-0162018-0082017-003The Department of Human Services? Division of Medical Assistance and Health Services (DMAHS) has unsuccessfully attempted to gain access to data files that would provide current licensure data to our contracted vendor from the State?s licensing agencies. Continuing efforts to outreach providers by sending a license expiration letter to providers 45 days prior to the license expiration date have also been less than successful. Access concerns have discouraged the State?s efforts to deny claims because of expired licenses. It is important to note that the State?s expectations are that providers are properly licensed, but have failed to communicate this information to our contracted vendor. Licensure information for all enrolling providers and those subject to revalidation are also screened in accordance with ACA requirements.DMAHS efforts to achieve compliance with regard to provider licensing in coordination with the State?s contracted vendor remains ongoing and the importance of having license information on file for the providers being enrolled will again be reiterated and reinforced through communications with the contracted vendor and their staff. The vendor has also been approved to continue taking screenshots of providers? licensing information from licensing websites in lieu of the provider sending in paper copies. These ongoing efforts and actions will help to ensure that licensing information is captured and maintained for each provider and the State?s compliance with documenting provider licensing continues to improve and move towards full compliance in future periods.COMPLETION DATE/CONTACT PERSON Fiscal Year 2023Carlton Carter(609) 588-7159Carlton.Carter@dhs.nj.gov

FINDING # 2022-005No finding in prior yearThe RESEA policy and controls presently in place at DLWD require eligibility interviews to be conducted and eligibility review forms to be completed and signed by the participant and UI program representative. DLWD will work to strengthen and reinforce these controls with responsible staff in an effort to ensure that all interviews are properly documented and eligibility review forms are signed and maintained on file for future reference and compliance support.COMPLETION DATE/CONTACT PERSON June 30, 2023Baden Almonor(609) 984-2477Baden.Almonor@dol.nj.gov

FINDING # 2022-0032021-007The Department of Labor and Workforce Development (DLWD) has controls in place to only allow an FPUC payment to be made when an underlying Unemployment Insurance (UI) payment has also been processed. FPUC payments should not be issued to any claim without the underlying UI payment being made for the same week. The two FPUC payments issued and noted as exceptions during eligibility testing will be reviewed independently by DLWD to determine if the payments issued were to eligible recipients or not.For the PUA exceptions noted during Eligibility testing, overall the DLWD issued PUA payments to over 680,000 claimants during the COVID-19 pandemic. DLWD had controls in place to require a COVID related reason to make the claim PUA eligible and the weekly PUA certification required claimants to choose a COVID related reason for why they were out of work before they could get paid. The PUA payments in question will be reviewed independently by the DLWD to determine if the payments issued under PUA were appropriate or if they should have been paid instead under the regular UI program.COMPLETION DATE/CONTACT PERSON February 2023Ronald Marino - DLWD(609) 292-2810Ronald.Marino@dol.nj.gov

Finding 2022-005Federal Program InformationFederal Agency: United States Department of EducationFederal Cluster: Student Financial AssistanceAward Periods: July 1, 2021 through June 30, 2022, and July 1, 2022 through June 30, 2023Corrective Action PlannedAnnual cost of attendance budgets uploaded to Mayo Clinic College of Medicine and Science?s student information system by the Program Manager of Student Financial Aid are reviewed and approved by another individual for accuracy once the upload is complete.Persons Responsible for Corrective ActionAnne Dahlen, Director of Student Financial Aid/Registrar Maribeth Foerster, Program Manager Student Financial AidTarget Completion DateSeptember 30, 2022

Foster Care Eligibility Controls Not Completed in a Timely MannerState Agency: Department of Health and Human ServicesFederal Program: Foster Care Title IV-EThe Department concurs with this recommendation. The agency is in the process of building an integrated eligibility team and will increase its capacity by having three team leads and one support coordinator III to support the eligibility review process.Anticipated Correction Date: June 30, 2023Contact Person: Tracy Wiggill, Eligibility Program Manager, twiggill@utah.gov

Annual Medicaid Eligibility Reviews Not CompletedState Agency: Department of Health and Human Services; Department of Workforce ServicesFederal Program: Medicaid ClusterDepartment of Health and Human ServicesThe Department concurs with this recommendation. The Department will coordinate with the Department of Workforce Services (DWS) to whom we have delegated authority to perform eligibility determinations for Medicaid and CHIP and will ensure that DWS properly follows policy sections 721-1.A.1.b.i and COVID-19 Q & A question 10. DWS will train staff on proper use of the asset verification system, as well as remind staff on the review policy. DWS? Performance Review Team will also review a sample of cases to ensure compliance with these policies.Anticipated Correction Date: February 28, 2023Contact Person: Michelle Smith, Assistant Office Director, Office of Eligibility Policy,michellesmith@utah.govDepartment of Workforce ServicesThe Department will coordinate with the Department of Health and Human Services (DHHS) and ensure policy sections 721-1.A.1.b.i and COVID-19 Q & A Question 10 are followed properly. We will train staff on proper use of the asset verification system, as well as remind staff of the review policy.Contact Person: Muris Prses - Assistant Director, Systems and Policy 801-526-9831Anticipated Correction Date: February 2023

Missing Documentation for Emergency Rental Assistance PaymentsState Agency: Department of Workforce ServicesFederal Program: Emergency Rental AssistanceA new process with updated procedures was implemented in March of 2022. This included adding two additional quality control analysts. We anticipate the program ending spring of 2023 based on remaining funds and current spend rate. For the next 4-6 months, monthly quality control reviews and training will occur with supervisors and staff.Contact Person: Lyle Ward, ERA Program ManagerAnticipated Correction Date: November 30, 2022

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.