Corrective Action Plans

Finding 442840 (2022-006)

Significant Deficiency 2022

South Montgomery Community School Corporation

IN

Special Tests & Provisions Subrecipient Monitoring School Nutrition Programs

FINDING 2022-006Contact Person Responsible for Corrective Action: Kristin CharlesContact Phone Number: 765-866-0203Views of the Responsible Official: The School Corporation is in agreement with the Finding.Description of Corrective Action Plan: This was the best process at the time. We are now doin...

FINDING 2022-006Contact Person Responsible for Corrective Action: Kristin CharlesContact Phone Number: 765-866-0203Views of the Responsible Official: The School Corporation is in agreement with the Finding.Description of Corrective Action Plan: This was the best process at the time. We are now doing negative expenditures to move the funds. The CAP is to contact another Komputrol school and see how they are processing the movement of funds from 8400 which is where the prepaid lunch money is supposed to go and how it is being moved into fund 800. The board has in essence through the superintendent for me to make posting corrections to get the amount into the proper funds. As the CFO/HR as well as the named treasurer, since this is not enough then we will work together to make sure it is clearly stated in resolution that the CFO/HR or named treasurer has the authority to make these moves in the funds.Anticipated Completion Date: ASAP

View Audit 312499

Finding 433484 (2022-003)

Significant Deficiency 2022

Nevada System of Higher Education

NV

Internal Control / Segregation of Duties Student Financial Aid Eligibility § 200.303

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 informa...

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.

View Audit 312392

Finding 433372 (2022-004)

Significant Deficiency 2022

Nevada System of Higher Education

NV

Special Tests & Provisions Student Financial Aid Reporting

FINDING 2022-004 - Special Tests and Provisions: Return of Title IV funds for withdrawn students(Repeat finding 2021-004, 2020-002, 2019-003, 2018-005, 2017-004, 2016-003, 2015-004, 2014-011)ResponsesCSN?? Detailed corrective action taken, including what will be done to avoid the identified issues i...

FINDING 2022-004 - Special Tests and Provisions: Return of Title IV funds for withdrawn students(Repeat finding 2021-004, 2020-002, 2019-003, 2018-005, 2017-004, 2016-003, 2015-004, 2014-011)ResponsesCSN?? Detailed corrective action taken, including what will be done to avoid the identified issues inthe future, and when these measures will be in place.All student accounts needing an R2T4 that require a date adjustment due to a gap between the lastdate of attendance for one course and the start of a new modular course will be reviewed by a secondindividual on the R2T4 processing team. This will ensure that the institution counts the correctnumber of complete days for the calculation when there is a gap in enrollment and a schedule breakof five days or more. These measures will be in place beginning October 15, 2022. Due to the error,the student will be made whole using institutional funds.? How compliance and performance will be measured and documented for future audit,management, and performance review.CSN will notate student accounts that must be reviewed as processors come across them. Who will be responsible and may be held accountable in the future if repeat or similarobservations are noted.The Assistant Director of Financial Aid will be responsible and may be held accountable if repeat orsimilar observations are noted.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:For context 1 (summer 2021), the student withdrawal occurred in FY 2021, with funds returned inAugust. This coincides with our 2020-2021 audit review, at which time many of the controlsdescribed in our response to findings for that year were in their early stages. Since summer 2021none of the identified issues that led to late fund returns have recurred.For context 2 (spring 2022), funds were returned one day late due to a failed transmission to theCommon Origination and Disbursement (COD) system. Normally when transmissions occur, anyrejected records are reviewed by the following day, in part to ensure that returns of funds are timely.In this particular instance, the file failed entirely and was never transmitted to COD at all, andtherefore no record was received of a file reject. Fortunately our own internal reconciliation controlsidentified the issue before even more time had passed.We regularly review records of when fund returns are processed in PeopleSoft to ensure reporting toCOD occurs within 45 days. In addition to our record of the PeopleSoft return date, we will nowtrack a second date to mark when the return record is accepted and reflected in COD. Thiscorrective action has been implemented as of October 10, 2022, and a review of fall 2022 R2T4returns to date indicates that all returns have been made within the 45-day timeframe.? How compliance and performance will be measured and documented for future audit,management and performance review:Steps taken in prior years, including expanded training around R2T4, the addition of a staff memberto support the R2T4 process, and increasing internal controls, have been successful in remediatingthe issues that were previously identified. To control for the file transmission issue, the correctiveplan will be monitored by both the Assistant Director for Financial Aid Processing and the ExecutiveDirector of Financial Aid & Scholarships on a weekly basis. Notes from these reviews will berecorded for future audits. Who will be responsible and may be held accountable in the future if repeat or similarobservations are noted:The Assistant Vice President for Admissions & Financial Aid and the Executive Director forFinancial Aid & Scholarships will be responsible for ensuring ongoing compliance.

View Audit 312392

Finding 433358 (2022-028)

Material Weakness 2022

State of Louisiana

LA

Procurement, Suspension & Debarment Eligibility Internal Control / Segregation of Duties

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 opportuni...

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.

View Audit 312391

Finding 433352 (2022-022)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Eligibility Internal Control / Segregation of Duties

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 distr...

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.

View Audit 312391 Questioned Costs: $1

Finding 433305 (2022-029)

Material Weakness 2022

State of Louisiana

LA

Special Tests & Provisions Reporting Internal Control / Segregation of Duties

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 13, 2023, regarding a reportable audit finding related to Noncompliance with Managed Care Provider Enrollment and Screening Requirement. LDH ...

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 13, 2023, regarding a reportable audit finding related to Noncompliance with Managed Care Provider Enrollment and Screening Requirement. LDH appreciates the opportunity to provide this response to your office's findings.Finding: Noncompliance with Managed Care Provider Enrollment and Screening RequirementRecommendation: LDH should ensure all providers are screened, enrolled, and monitored as required by federal regulations.LDH Response: LDH partially concurs with your finding that LDH did not enroll and screen Healthy Louisiana managed care providers and dental managed care providers as required by federal regulations in 2022.LDH amended the Gainwell Technologies contract to accomplish provider revalidations, with CMS - approved funding. Gainwell Technologies was able to construct an online application portal, which launched in July 2021. Since then, 38,618 fee for service (FFS) and managed care entities (MCE) providers have successfully gone through the portal and submitted their application to be enrolled with 37,613 completing enrollment. Throughout 2022 Gainwell Technologies continued to make user-friendly enhancements to the portal, such as adding a provider enrollment portal lookup tool to show the provider's status as either enrollment complete, action required, application not submitted, or currently in process by Gainwell Technologies. The department and MCEs also completed extensive outreach efforts such as direct contact, hand delivered letters, and provider webinars aimed at unenrolled providers during 2022.Providers who had not completed enrollment on or before December 31, 2022, will have their claims denied for dates of service on or after January 1, 2023.Corrective Action PlanLDH is seeking a longer-term solution through the National Association of State Procurement Officials (NASPO) Value Point that will modernize the provider management system and achieve the CMS preference of modularity. The new Provider Management Module solution will be a modern, web based, self-service solution that will support provider enrollment, re-validation, and maintenance. The vendor will provide a configurable, web based, self-service solution that allows healthcare providers to enroll electronically and provide an option for provider self-service updates. LDH continues to keep CMS informed of our progress toward achieving compliance with CMS regulations.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.

View Audit 312391

Finding 433302 (2022-025)

Significant Deficiency 2022

State of Louisiana

LA

Internal Control / Segregation of Duties

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated February 6, 2023, regarding a reportable audit finding related to billing controls for behavioral health services. LDH appreciates the opportunity to provi...

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated February 6, 2023, regarding a reportable audit finding related to billing controls for behavioral health services. LDH appreciates the opportunity to provide this response to your office's findings.Finding: Inadequate Controls over Billing for Behavioral Health Services.Recommendation: LDH management should implement adequate internal controls to ensure that encounters are coded correctly, which could include edit checks to flag potential improper billings for further review.LDH Response:LDH concurs.As noted in previous audit responses, LDH holds the Managed Care Organizations (MCOs) accountable for implementing necessary claim system edits, as identified in the FY2022 contracts between Bureau of Health Services Financing (BHSF) and each individual MCO. Further, the MCOs must incorporate all National Correct Coding Initiative (NCCI) edits to applicable claims, as well as have the ability to update national standard code sets such as Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (CPT/HCPCS), International Classification of Diseases Codes (ICD-10-CMS), and move to future versions as required by CMS or LDH.In order to meet the above requirements, the MCOs implement a variety of edits that are not dependent on the use of modifiers, including the use of information readily available through interfaces with their provider enrollment and service authorization data. The multiple systems that interface with the MCOs' claims processing systems assist in the validation of claims accuracy based on information such as the provider's qualifications and specialties, the appropriate fee schedule and/or contracted rate for which the provider is eligible, the number and types of services for which the recipient is authorized and the eligibility of the recipient for the service. This is the most effective way for the MCO to adjudicate the claims while reducing administrative burden and preventing provider abrasion. This results in the MCO not being dependent upon modifiers, which may or may not be valid, to process and pay these claims as clean, rather than denying and requiring unnecessary resubmission. The MCOs are also required to perform internal audit reviews to confirm claim edits are functioning properly.System edit checks are a critical function of ensuring the appropriateness of claims payments. However, these edits and functions should not conform to the standard Medicaid SBHS schedule in that this would interfere with the requirement to be adaptable to continuously changing provider specific agreements, out of network agreements, recipient specific agreements; in addition to the accommodation of all of the nuances related to billing and payment methodologies required and/or allowed in contract and as permitted via a variety of Medicaid programs and fee schedules.In reality, claims adjudication systems are incapable of accounting for every variable in a managed care environment that not only encourages, but also requires, flexibility related to alternative payment methodologies. These methodologies include incentivizing providers in rural and other areas with limited access to necessary services; in response to individual client cases in order to ensure that their person-centered medical needs are met, and defining payment rates based on outcomes and performance versus volume.While the managed care entity's independent claims system can accommodate a number of edits, an encounter repository system such as Medicaid's Data Warehouse is further limited as it would be impossible to implement uniform edits across multiple managed care entities which pay varying rates, offer varying services, hold unique provider specific agreements and offer provider specific incentives.Medicaid's Managed Care model places emphasis on efficacy and efficiency, which may not necessarily align with hard coded claims logic across multiple populations, providers and patients' varying medical needs. MCOs may offer additional benefits and rates that are outside the scope and fee of core State Plan benefits and services to individual members on a case-by-case basis, based on medical necessity, cost-effectiveness, the wishes of the member and/or member's family, the potential for improved health status of the member, and functional necessity.In a preliminary review of unique claim numbers provided by the LLA, OBH identified several instances where the SBHS fee schedule was not the source document and where the rate paid did align with the Medicaid rate on file. In reviewing data related to "Bad Modifiers", OBH found more than 5,000 encounters to contain no behavioral health diagnosis. Examples of questionable encounters include those for family practice physician clinics, neurologists, OME, newborn and well child visits, diabetes and hypertension diagnoses. Because Healthy Louisiana Plans pay both physical and behavioral health claims, manually sorting through encounters has shown a wide variety of services are being captured in the review. In combination with just a very small sample of physicians as identified through our partial review, we are questioning over 5,000 encounters totaling over $490,000.Corrective Action PlanLDH will continue to review best practices related to the independent claims processing systems of MCOs, and ensure compliance with and, as needed, development of, contract language to ensure due diligence on their part. Further, LDH has contracted with a third party through the LDH Medicaid office for expansion of the CMS External Quality Review, Protocol 5. While hard edits of encounters against the Medicaid fee schedule are not feasible in Managed Care due to the flexibility MCEs have in reference to payment methodologies for their contracted providers, the EQR will include validation of a representative sample of encounters against the Medicaid fee schedule on file at the time of service delivery, inclusive of modifier utilization .OBH will investigate any discrepancies in order to identify whether those encounters are reflective of an approved alternate payment rate or agreement versus a claim paid outside of the fee schedule, in error. MCEs will be responsible for addressing any erroneous claims inclusive of adjustments or necessary recoupments. Implementation of this protocol began in SFY 2022, with the first report covering the second quarter of the fiscal year that is the basis of this audit. The initial report is due prior to the end of SFY 2023.You may contact Karen Stubbs, OBH Assistant Secretary by telephone at (225) 342-1435 or by e-mail at karen.stubbs@la.gov with any questions concerning this matter.

View Audit 312391

Finding 433301 (2022-023)

Material Weakness 2022

State of Louisiana

LA

Special Tests & Provisions Internal Control / Segregation of Duties

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 Inadequate Controls and Noncompliance over ADP Risk Analysis and System Security R...

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 Inadequate Controls and Noncompliance over ADP Risk Analysis and System Security Review. LDH appreciates the opportunity to provide this response to your office?s findings.Finding: Inadequate Controls and Noncompliance over ADP Risk Analysis and System Security Review.Recommendation: LDH should design and implement procedures to document and support its review of all ADP system security reports.LDH Response: LDH partially concurs with this finding.LDH received and reviewed Service Organization Control (SOC) 1 reports, however there was no written communication between LDH and Magellan regarding the reports. LDH will respond to Magellan SOC 1 reports in writing in the future. LDH Pharmacy adopted the SOC 1 Audit Report procedure for SOC audit review in January 2023 and will utilize it for SFY2023 and subsequent years.LDH did not request a CAP for the requested reports due to the following:? The report indicated controls were not operating effectively however it was determined the controls were not related to Louisiana:o The cover letter and Section V, Other Information Provided by Magellan Rx Management, LLC, note ?Management?s Responses to Exceptions Noted? section Magellan indicated ??is not a part of Magellan Rx?s description of its Rebate Processing system made available to user entities during the period July 1, 2021 to June 30, 2022, hence is not applicable to LDH.?? In addition, Magellan management provided responses, which clarified or rectified the exceptions noted.Corrective Action PlanLDH will respond to Magellan SOC 1 reports in writing in the future. LDH Pharmacy adopted the SOC 1 Audit Report procedure for SOC audit review in January 2023, and will utilize it for SFY2023 and subsequent years.You may contact Tara A. LeBlanc at (225) 219-7810 or via e-mail at Tara.LeBlanc@LA.GOV or Germaine Becks-Moody, Medicaid Program Manager at (225) 342-9479 or via email at germaine.becks-moody@la.gov with any questions about this matter.

View Audit 312391

Finding 433293 (2022-020)

Significant Deficiency 2022

State of Louisiana

LA

Special Tests & Provisions Internal Control / Segregation of Duties

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has received the finding titled "Noncompliance and Control Weakness relating to the Temporary Assistance for Needy Families (TANF) Work Verification Plan."The finding states the Department of Children and Family Services (DCFS...

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has received the finding titled "Noncompliance and Control Weakness relating to the Temporary Assistance for Needy Families (TANF) Work Verification Plan."The finding states the Department of Children and Family Services (DCFS) did not ensure that all work activity supporting documentation for cash assistance recipients was accurate and maintained for hours worked under the Temporary Assistance for Needy Families (TANF) program. DCFS concurs with the finding and will ensure proper documentation through training and case reviews.In alignment with the Department's continued improvements, we have restructured the Department to bring TANF and Workforce Development under the same umbrella to provide training and additional oversight of the STEP program. The TANF consultants will review the Strategies to Empower People (STEP) cases monthly to ensure work activities are properly documented in the Louisiana Integrated Technology for Eligibility (LITE) system and to improve the outcomes of TANF participants. This process is ongoing and began this month.The Temporary Assistance for Needy Families (TANF) grants increased in January 2022. As a result, the number of participants in the STEP program doubled. The STEP coaches were working forty (40) cases per month, and this jumped to one hundred (100) cases after the grant increase. The Louisiana Department of Children & Family Services has been working expeditiously to bring additional staff on board and meet the demands of this vulnerable population. Training has been revamped with a laser focus on documentation, policy, systems, and the Goal4 It! Case Management model. The Goal4 It! model invokes core self-regulation skills such as planning, prioritization, and metacognition which creates opportunities for the STEP participant to practice this approach with their personal and employment-related goals. Statewide training will be completed on March 3, 2023.In addition, we are entering new contractual agreements with organizations throughout Louisiana. The STEP participants will have access to a variety of employers, training providers, and work activities. More recently, we have contracted with South Louisiana Community College and the Prosperity Center at United Way of Southeast Louisiana.Technological systems improvements are underway in the TANF/STEP programs to allow for more effective reporting and data analysis. DCFS continues to work with vendors to align the Louisiana Integrated Technology for Eligibility (LITE) system with the Goal4It! Model. We look forward to the new enhancements which will give the STEP coaches the opportunity to fully document all case actions including good cause determinations. Integration of the TuaPath system with LITE is also underway. TuaPath is a case management tool accessible to both participants and coaches. It provides greater accountability for participants to set their own goals, enter participation hours, and upload documentation. The enhancement of the LITE system and the implementation of Tuapath will assist DCFS in reporting work activities. The LITE and TuaPath integration is slated for completion at the end of July 2023.If you have any additional questions, please reach out to Deputy Assistant Secretary Lorrie Briggs, who oversees TANF and the associated work program STEP. You can reach her at (337) 344-9676 or Lorrie.Briggs.DCFS@la.gov.

View Audit 312391

Finding 433281 (2022-015)

Significant Deficiency 2022

State of Louisiana

LA

Reporting Internal Control / Segregation of Duties

Dear Mr. Waguespack:Listed below is the University's response to the finding regarding Control Weakness over Higher Education Emergency Relief Funds ReportingFINDING: Control Weakness over Higher Education Emergency Relief Funds ReportingRESPONSE: Southern University - Baton Rouge (SUBR) concurs in ...

Dear Mr. Waguespack:Listed below is the University's response to the finding regarding Control Weakness over Higher Education Emergency Relief Funds ReportingFINDING: Control Weakness over Higher Education Emergency Relief Funds ReportingRESPONSE: Southern University - Baton Rouge (SUBR) concurs in part with the above noted finding.The University does not concur that this is the third consecutive year to have the same reported weaknesses. The University did implement corrective action for the prior year audit finding. Of the three bullets included in the prior year audit finding, the University did not concur with one of the bullets, based on its interpretation of the United States Department of Education (USDOE) reporting requirements, and the two remaining bullets, wherein the University did concur, were corrected and are not a part of the condition of this finding. In addition, the timely implementation of recommendations demonstrates the University's management desire to be accountable for, and a willingness to improve, their operations.The University concurs with the current year's weaknesses wherein there was an understatement of expenditures on the Higher Education Emergency Relief Funds (HEERF) on two of the quarterly reports in the amount of $1,216,444 and on the annual report in the amount of $1,674,977. Due to a change in the USDOE reporting requirements, which specifically changed the quarterly reporting from cumulative to not cumulative, the University revisited the quarterly reports that were posted on the website to make the requested revisions and inadvertently understated the expenditures.At the time these two quarterly reports were prepared and posted, the USDOE had a requirement, which has since been revised, that the reports agree to the expenditures recorded, not the drawdown amounts. There is a USDOE requirement that all quarterly reports are posted by the 10th day following the end of the quarter, which results in the University preparing the reports immediately after the end of the quarter to meet the deadline. Therefore, generating a list of all transactions after the entire year has closed, to include the accrual period and comparing it to the transactions that were posted for the quarter to meet the deadline, resulted in an understatement of expenditures on the reports. Also, the University concurs that the age category was misclassified for 145 students (1.4% error rate).The USDOE allowed all reporting entities to revise the HEERF Annual 2021 data when entering the 2022 data into the HEERF portal. The USDOE has confirmed that the University may charge its HEERF grant awards for expenditures from March 13, 2020 through the performance period of the HEERF grants.The University will continue to review the USDOE website and attend webinars for guidance related to HEERF reporting requirements. Management will continue to monitor the concerns noted in this finding.The campus personnel responsible for implementing and monitoring corrective actions are Mr. Flandus McClinton, Vice President for Finance and Business Affairs and Mr. Terry Hall, Vice Chancellor for Financial Affairs. The projected deadline to finalize the review of the concerns brought to the University's attention with this audit finding is June 30, 2023.If you have any questions or require additional information, please contact Mr. Flandus McClinton at 225.771.6278.

View Audit 312391

Finding 433276 (2022-014)

Significant Deficiency 2022

State of Louisiana

LA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Dear Mr. Waguespack,Please accept this letter as the official response from the Louisiana Department of Education (LDOE) to the audit finding entitled Non-Compliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA) for the fiscal year ending June 30, 20...

Dear Mr. Waguespack,Please accept this letter as the official response from the Louisiana Department of Education (LDOE) to the audit finding entitled Non-Compliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA) for the fiscal year ending June 30, 2022.Recommendation:DOE should continue to strengthen internal controls to ensure that appropriate personnel are aware of the federal programs that are subject to FFATA reporting and assign appropriate personnel to complete the FFATA reporting in accordance with federal requirements.LDOE Response:In order to strengthen internal controls over FFATA reporting to address the recommendation, the LDOE has implemented procedures to identify appropriate personnel as responsible for the preparation and submission of FFATA reporting in addition to providing training to the responsible personnel on federal regulations regarding required reporting. The agency?s third-party electronic grants management system vendor has provided the reports for FFATA Reporting that ensures accurate data submission in accordance with the federal requirements, therefore the LDOE concurs with the finding. The LDOE plans to have these corrective actions in place no later than September 30, 2023.Contributing Factor:As part of the formal response, LDOE would like to identify the Federal Subaward Reporting System (FSRS) as a contributing factor in the resolution process for FFATA reporting. While LDOE is and will continue to work through the process of submission/correction to FFATA reporting, please note that timely/accurate submission is to some extent dependent on the submission process as designed by the FSRS. LDOE has and continues to encounter technical issues with the FSRS site where these reports are uploaded. To resolve the issues, the staff must submit FSRS Helpdesk tickets whereas the timely resolution of the tickets are a vital component of the corrective action protocols. Upon request, LDOE provides our program contact at the US Department of Education (ED) information regarding its outstanding helpdesk tickets and their status for resolution. The agency?s team is maintaining a record regarding the ticket submissions and their resolution status to ensure all FFATA reports are submitted accurately and timely.The Department takes seriously the reporting requirements for FFATA and is dedicated to ensuring the reporting is accurate and timely. Further questions concerning this response may be directed to Mr. Bernell Cook, by telephone at 225-342-1050 or via email at bernell.cook@la.gov.

View Audit 312391

Finding 433266 (2022-012)

Material Weakness 2022

State of Louisiana

LA

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

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 fed...

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

View Audit 312391

Finding 425828 (2022-006)

Material Weakness 2022

Commonspirit Health

IL

Eligibility Internal Control / Segregation of Duties Material Weakness § 200.303

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...

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

View Audit 312373

Finding 425672 (2022-013)

Material Weakness 2022

Commonspirit Health

IL

Questioned Costs Allowable Costs / Cost Principles Cash Management

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

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

View Audit 312373 Questioned Costs: $1

Finding 425615 (2022-003)

Material Weakness 2022

Commonspirit Health

IL

Student Financial Aid Material Weakness Reporting § 200.303

REFERENCE: 2022-003 ? Reporting ? Common Origination and Disbursement (COD) SystemStudent Financial Assistance Cluster (Assistance listing No. 84.063)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing ...

REFERENCE: 2022-003 ? Reporting ? Common Origination and Disbursement (COD) SystemStudent Financial Assistance Cluster (Assistance listing No. 84.063)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing & Health Science did not perform its internal control over therequirement to submit Pell payment data to the Department of Education through the COD system, which consists ofmonthly Pell COD reconciliations.Corrective Action Plan: Good Samaritan will implement a formal monthly reconciliation process, includingcomparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting anyexplaining any differences, proper sign off for preparation and review and the date by Good Samaritan management.A year end reconciliation will also be performed following the same process.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health Scienceand Financial Aid Services (FAS)Completion: June 2022

View Audit 312373

Finding 425613 (2022-005)

Significant Deficiency 2022

Commonspirit Health

IL

Special Tests & Provisions Reporting Significant Deficiency § 200.303

REFERENCE: 2022-005 ? Special Tests and Provision ? Enrollment ReportingStudent Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nu...

REFERENCE: 2022-005 ? Special Tests and Provision ? Enrollment ReportingStudent Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollmentreporting.Corrective Action Plan: Monthly reconciliations are conducted by the Bursar and Financial Aid departments.Monthly reconciliation reports are presented to the Dean of Enrollment Management at all monthly reconciliationupdate meetings.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health ScienceCompletion: June 2022

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Finding 425612 (2022-004)

Material Weakness 2022

Commonspirit Health

IL

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2022-004 ? Cash ManagementStudent Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Per discussion with management, Good Samaritan College of Nursi...

REFERENCE: 2022-004 ? Cash ManagementStudent Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Per discussion with management, Good Samaritan College of Nursing & Health Science has processes andinternal controls in place to ensure requests for funding are allowable under the terms of the grant agreement. Theseinternal controls included validating the draw agreed between the G5 system, COD, and Good Samaritan College ofNursing & Health Science?s internal records for student financial need. However, management did not consistentlyretain documentation evidencing the performance of these internal controls.Corrective Action Plan: Good Samaritan will implement a formal monthly reconciliation process, includingcomparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting anyexplaining any differences, proper sign off for preparation and review and the date by GSC management and FASmanagement. A year end reconciliation will also be performed following the same process.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health ScienceCompletion: June 2022

View Audit 312373

Finding 424958 (2022-208)

Material Weakness 2022

State of Idaho

ID

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

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

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

View Audit 312368

Finding 424955 (2022-211)

Significant Deficiency 2022

State of Idaho

ID

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.510

Finding Number 2022-211: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller did not properly identify COVID-19 Emergency Acts expenditures for multiple programs.Federal Programs:93.391 - Activities to Support State, Tribal...

Finding Number 2022-211: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller did not properly identify COVID-19 Emergency Acts expenditures for multiple programs.Federal Programs:93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises10.551 - Supplemental Nutrition Assistance Program (Snap)84.181 - Special Education - Grants for Infants and Families93.497 - Family Violence Prevention and Services/ Sexual Assault/Rape Crisis Services and Supports93.590 - Community-Based Child Abuse Prevention Grants93.958 - Block Grants for Community Mental Health Services93.977 - Sexually Transmitted Diseases (STD) Prevention and Control Grants10.557 - WIC Special Supplemental Nutrition Program for Women, Infants, And Children10.561 - State Administrative Matching Grants for The Supplemental Nutrition Assistance ProgramRelated to Prior Finding: 2021-206Agency?s view: The Department agrees with this finding.The Department agrees with this finding but it is important to highlight that our internal controls and review processes are designed to detect and correct material inaccuracies or omissions of required information within the annual SEFA. As this does not constitute a material error, but rather a significant deficiency, the Department?s controls for this process worked as intended.This was a new requirement and Department personnel failed to identify a significant risk related to it and enhance the review procedures accordingly. This requirement will be monitored while we spend down the remaining COVID-19 emergency funding we have already been awarded.Corrective Action: This corrective action plan is complete. Effective immediately, we willmonitor awards for any new COVID-19 funding, but we don?t believe that there will be any newCOVID-19 awards. All existing awards have been confirmed as being reported as COVID-19funding.Anticipated Corrective Action Date: Corrective action has been taken as of April 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

View Audit 312368

Finding 424954 (2022-204)

Material Weakness 2022

State of Idaho

ID

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.502 § 200.510

Finding Number 2022-204: $196,247,971 was not properly identified as covid-19 funds on the statewide Schedule of Expenditures of Federal Awards (SEFA).Federal Programs:10.551 - Supplemental Nutrition Assistance Program (SNAP)10.557 - WIC Special Supplemental Nutrition Program for Women, Infants, and...

Finding Number 2022-204: $196,247,971 was not properly identified as covid-19 funds on the statewide Schedule of Expenditures of Federal Awards (SEFA).Federal Programs:10.551 - Supplemental Nutrition Assistance Program (SNAP)10.557 - WIC Special Supplemental Nutrition Program for Women, Infants, and Children10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program64.005- Grants to States for Construction of State Home Facilities84.181 - Special Education - Grants for Infants and Families84.425R - Education Stabilization Fund - Emergency Assistance for Non-Public Schools93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises93.497 - Family Violence Prevention and Services/ Sexual Assault/Rape Crisis Services and Supports93.590 - Community-Based Child Abuse Prevention Grants93.958- Block Grants for Community Mental Health Services93.977 - Sexually Transmitted Diseases (STD) Prevention and Control Grants97.036 - Disaster Grants - Public Assistance (Presidentially Declared Disasters)Related to Prior Finding: N/AAgency?s view: The Office agrees with this finding.Corrective Action: Since the State began receiving COVID-19 funding, we diligently provided training and resources to the agencies regarding the funding and how it should be reported on the SEFA closing package. This includes a discussion in our annual closing package training, online resources regarding COVID-19 funds, an FAQ document, and being available to discuss questions and concerns. In addition to the steps we are currently taking, we will reiterate the importance of designating COVID-19 related expenditures on the SEFA closing package during our annual closing package training. We will review STARS activity in the COVID-19 related funds and compare to the agency submitted closing packages for reasonableness. Recognizing that not all agencies utilize these specific funds, we will also review COVID-19 related expenditures on an external online source that reports federal grant expenditures. We will then use this information to compare to what is reported on agency closing packages for reasonableness.Anticipated Corrective Action Date: Errors identified were corrected prior to issuance of the Single Audit report. We will work with agencies to ensure all COVID-19 funds are identified for FY23 reporting.Responsible for Corrective Action: Ethan Draves, Reporting and Review Bureau ChiefEdraves@sco.idaho.gov 208-334-3100

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Finding 424932 (2022-203)

Significant Deficiency 2022

State of Idaho

ID

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.502 § 200.510

Office of the State ControllerFinding Number 2022-203: Errors in the elimination process between state agencies resulted in misstatements to the Schedule of Expenditures of Federal Awards (SEFA) totaling $14,656,928 for direct awards and $14,278,362 for expenditures provided to subrecipients.Federal...

Office of the State ControllerFinding Number 2022-203: Errors in the elimination process between state agencies resulted in misstatements to the Schedule of Expenditures of Federal Awards (SEFA) totaling $14,656,928 for direct awards and $14,278,362 for expenditures provided to subrecipients.Federal Programs:21.027 - State and Local Fiscal Recovery Fund84.334S - Gaining Early Awareness and Readiness for Undergraduate ProgramsRelated to Prior Finding: N/AAgency?s view: The Office agrees with this finding.Corrective Action: We will improve our elimination and reporting process by adding the following steps:? We will add an additional tab to our SEFA Master file to cross check all COVID-19 related funding to ensure agencies are not double reporting expenditures.? We will add additional steps to our SEFA preparation and review checklist outlining specific steps for completing the subrecipient elimination process, and identify higher risk areas that require the most scrutiny.? We will also improve our current elimination tab (awards received from other state agencies) and reconciliation procedures for subrecipients.Anticipated Corrective Action Date: Errors identified were corrected prior to issuance of the Single Audit report. Changes to the subrecipient reporting process will occur for FY23 reporting.Responsible for Corrective Action: Ethan Draves, Reporting and Review Bureau ChiefEdraves@sco.idaho.gov 208-334-3100

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Finding 424930 (2022-207)

Significant Deficiency 2022

State of Idaho

ID

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.502 § 200.510

Finding Number 2022-207: The amount reported as passed through to subrecipients on the Schedule of Expenditures of Federal Awards (SEFA) closing package was overstated by $331,500.Federal Programs:15.605 - Sport Fish Restoration15.611 - Wildlife Restoration and Basic Hunter EducationRelated to Prior...

Finding Number 2022-207: The amount reported as passed through to subrecipients on the Schedule of Expenditures of Federal Awards (SEFA) closing package was overstated by $331,500.Federal Programs:15.605 - Sport Fish Restoration15.611 - Wildlife Restoration and Basic Hunter EducationRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.Corrective Action: The Department will provide additional training and update its procedural documentation to ensure that expenses are thoroughly vetted before they are reported as subrecipient expenditures on the SEFA. Each expenditure identified as a subrecipient expense will be tied back to a specific subaward, further limiting the possibility of non-subaward expenses being reported in the subrecipient portion of the SEFA.Anticipated Corrective Action Date: This corrective action plan will be implemented by the end of August 2023.Responsible for Corrective Action: Michael Pearson, Chief, Bureau of Administrationmichael.pearson@idfg.idaho.gov(208) 287-2800Jon Oswald, Financial Managerjonathan.oswald@idfg.idaho.gov(208) 287-2820

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Finding 424928 (2022-209)

Material Weakness 2022

State of Idaho

ID

Equipment & Real Property Management Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Finding Number 2022-209: An annual physical inventory was not completed for all storage facilities used by sub-distributing agencies for the Emergency Food Assistance Program as required by federal guidance.Federal Program: 10.568 - Emergency Food Assistance ProgramRelated to Prior Finding: N/AAgenc...

Finding Number 2022-209: An annual physical inventory was not completed for all storage facilities used by sub-distributing agencies for the Emergency Food Assistance Program as required by federal guidance.Federal Program: 10.568 - Emergency Food Assistance ProgramRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.Corrective Action: The Department questioned and relied upon an opinion from the National Office of USDA Food and Nutrition Service (FNS), which administers TEFAP, affirming the Department?s interpretation of the regulations for this program. Dixon, R. (2023) Email to Cho Heide, March 23. In that opinion the Department asserted and FNS agreed that the requirements for an annual physical review of food inventories only applies to storage facilities used by the state distributing agency or sub-distributing agencies (as defined in 7 CFR 250.2). The Department has always considered the organizations with which we have subgrant agreements for TEFAP to be eligible recipient agencies (as defined in 7 CFR 251.3), not sub-distributing agencies. The Department provided this information to LSO auditors but on review with them as relates to the compliance supplement for this program, it became clear that the guidance from FNS was not authoritative and therefore, did not supersede the compliance supplement. With this knowledge, the Department will work with FNS to clarify requirements within the compliance supplement, revising our control process in this program accordingly.Anticipated Corrective Action Date: July 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

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Finding 424926 (2022-212)

Material Weakness 2022

State of Idaho

ID

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Finding Number 2022-212: The Department did not maintain consistent operation of controls and compliance with Electronic Benefit Transfer (EBT) Card Security procedures for the Supplemental Nutrition Assistance Program (SNAP).Federal Programs:10.551 - Supplemental Nutrition Assistance Program (SNAP)...

Finding Number 2022-212: The Department did not maintain consistent operation of controls and compliance with Electronic Benefit Transfer (EBT) Card Security procedures for the Supplemental Nutrition Assistance Program (SNAP).Federal Programs:10.551 - Supplemental Nutrition Assistance Program (SNAP)10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance ProgramRelated to Prior Finding: 2021-210Agency?s view: The Department agrees with this finding.Corrective Action: Immediately upon receiving the audit finding in March 2022, staffreviewed and revised procedures and fully implemented a corrective action plan by June 30, 2022. The entire EBT team was trained on the bulk card ordering and issuing process and modified security procedures to mitigate the risk of non-compliance in the future. The bulk card managers in the field offices review and reconcile card issuances monthly. Also, the EBT Supervisor documents the review of the previous quarter?s electronic card audits for accuracy and completeness.Anticipated Corrective Action Date: See corrective action above.Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

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Finding 423470 (2022-001)

Significant Deficiency 2022

State System of Higher Education, Commonwealth of Pennsylvania

PA

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

LockHaven: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to fi...

LockHaven: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The University will review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. The University will put necessary controls in place to ensure reports are posted within ten days of the end of the quarter. Documentation of report review and approval will be in writing and saved to ensure documentation is available to support review and approval of report submissions.Name(s) of the contact person(s) responsible for corrective action: Michael Hall, Director of Financial Aid.Planned completion date for corrective action plan: April 30, 2023Clarion: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: This finding resulted from a combination of staff turnover and the complexity of integration. All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304Planned completion date for corrective action plan: June 30, 2023Bloomsburg: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: We have reviewed the reporting requirements published by the federal government to ensure compliance with all procedures. In addition, we have established review procedures so that each document is reviewed prior to publishing on our website.Name(s) of the contact person(s) responsible for corrective action: : Amanda Kishbaugh at (570) 389-4497.Planned completion date for corrective action plan: April 30, 2023Edinboro: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304. Planned completion date for corrective action plan: 06/30/2023California: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: This finding resulted from a combination of staff turnover and the complexity of integration. All grant-related reporting requirements will be reviewed to ensure that they are properly documented and scheduled for completion and review when required by the granting authority.Name(s) of the contact person(s) responsible for corrective action: Sean Bliley, Controller, 814-732-1304Planned completion date for corrective action plan: June 30, 2023 Mansfield: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The University will review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately. Documentation of report review and approval will be in writing and saved to ensure documentation is available to support review and approval of report submissions.Name(s) of the contact person(s) responsible for corrective action: Colleen Jackson, Assistant Controller, Pam Kathcart, Director of Financial AidPlanned completion date for corrective action plan: April 30, 2023 Millersville: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The finding related to the institutional report not being displayed on the website refers to reporting of December 31st, 2021 (due to be posted on website by January 10th, 2022). The university was alerted to the issue of approval requirements during the last single audit process, which was after the December 31st report was posted. All reports posted to the website after the finding in last year?s audit were completed with Finance and Administration Vice President or Associate Vice President approvals prior to posting.Name(s) of the contact person(s) responsible for corrective action: Tammy Aument-Martin, Director of Accounting & Budget at 717-871-4091 and Emi Alvarez, Director of Financial Aid at 717-871-5100.Planned completion date for corrective action plan: 06/30/2022 (all HEERF funds were drawn down and recorded) Cheyney: Recommendation: The University should review its policies and procedures around grant reporting to ensure all reporting requirements are met timely and accurately.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Additional policies and procedures were implemented to mitigate errors in the future.Planned completion date for corrective action plan: 9/30/2023Name(s) of the contact person(s) responsible for corrective action: Victoria Atkins at (610) 399-2097.

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