Corrective Action Plans

Finding 544155 (2024-004)

Significant Deficiency 2024

MD

Questioned Costs Matching / Level of Effort / Earmarking § 200.303

Action taken in response to finding: Move all promissory notes to a fireproof filing cabinet, that is stored in a secure area. Each promissory note has been backed up electronically. Assign all defaulted and potential default loans to the Department of Education. Name(s) of the contact person(s) res...

Action taken in response to finding: Move all promissory notes to a fireproof filing cabinet, that is stored in a secure area. Each promissory note has been backed up electronically. Assign all defaulted and potential default loans to the Department of Education. Name(s) of the contact person(s) responsible for corrective action: Patrick Farley Planned completion date for corrective action plan: June 30, 2026

View Audit 350924 Questioned Costs: $1

Finding 544140 (2024-005)

Significant Deficiency 2024

Washington Adventist University

MD

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

Action taken in response to finding: Washington Adventist University will review Institutional charges used in R2T4 to ensure that all institutional charges used in R2T4 calculations are accurate and align with federal definitions. Regular training sessions will be conducted for staff involved in R...

Action taken in response to finding: Washington Adventist University will review Institutional charges used in R2T4 to ensure that all institutional charges used in R2T4 calculations are accurate and align with federal definitions. Regular training sessions will be conducted for staff involved in R2T4 process to ensure they understand the requirements and procedures and also implement a system of review calculations and R2T4 cases before submission. Name(s) of the contact person(s) responsible for corrective action: Alfred Taylor Planned completion date for corrective action plan: June 30, 2025

View Audit 350924

Finding 544139 (2024-003)

Significant Deficiency 2024

Washington Adventist University

MD

Questioned Costs Eligibility Student Financial Aid § 200.303

Action taken in response to finding: The University has SAP policies and procedures in place to determine student’s eligibility for Financial Aid that complies with Federal regulations, including qualitative (GPA), quantitative (pace of completion) and maximum timeframe standards. The SAP finding m...

Action taken in response to finding: The University has SAP policies and procedures in place to determine student’s eligibility for Financial Aid that complies with Federal regulations, including qualitative (GPA), quantitative (pace of completion) and maximum timeframe standards. The SAP finding may be due to system error with the Colleague ERP when the SAP report was run. The University will evaluate our SAP procedures and perform internal audits to identify gaps or inconsistencies and implement corrective actions as needed. Training will be provided to financial aid staff on SAP requirements and procedures to ensure consistent application and understanding. Name(s) of the contact person(s) responsible for corrective action: Alfred Taylor Planned completion date for corrective action plan: June 30, 2025

View Audit 350924 Questioned Costs: $1

Finding 544138 (2024-002)

Material Weakness 2024

Washington Adventist University

MD

Student Financial Aid Internal Control / Segregation of Duties Cash Management § 200.303

Action taken in response to finding: Washington Adventist University (WAU) is evaluating its current internal control and will make the necessary improvements so as to assure accuracy and compliance with the laws and regulations applicable to WAU. Furthermore, WAU will map internal control to impro...

Action taken in response to finding: Washington Adventist University (WAU) is evaluating its current internal control and will make the necessary improvements so as to assure accuracy and compliance with the laws and regulations applicable to WAU. Furthermore, WAU will map internal control to improve segregation of duties where possible and follow the Committee of Sponsoring Organizations of the Treadway Commission best practices for small business. Name(s) of the contact person(s) responsible for corrective action: Alfred Taylor Planned completion date for corrective action plan: June 30, 2025.

View Audit 350924

Finding 544136 (2024-001)

None 2024

Trinity Christian College

IL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

All graduate and withdrawn student files will be reviewed on a monthly basis to verify any status changes are reported to NSLDS within regulatory timeframes. Training and professional development will be required for responsible staff to ensure a compliance schedule is developed. Personnel will be e...

All graduate and withdrawn student files will be reviewed on a monthly basis to verify any status changes are reported to NSLDS within regulatory timeframes. Training and professional development will be required for responsible staff to ensure a compliance schedule is developed. Personnel will be evaluated to ensure existing policies, procedures, and processes are followed and supported through corrective action where needed.

View Audit 350923

Finding 544082 (2024-001)

Significant Deficiency 2024

Bridgewater College

VA

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

2024-001 Enrollment Reporting (Significant Deficiency), Department of Education, Student Financial Aid Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Unless it ...

2024-001 Enrollment Reporting (Significant Deficiency), Department of Education, Student Financial Aid Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Unless it expects to submit its next updated enrollment report to the Secretary within the next 60 days, a school must notify the Secretary within 30 days after the date the school discovers that a loan under Title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the school, and the student has ceased to be enrolled on at least a half-time basis or failed to enroll on at least a half-time basis for the period for which the loan was intended (34 CFR 685.309(b)(2)(i)). Cause: The College does not have adequate procedures in place to ensure students’ enrollment statuses are updated on NSLDS timely. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the students’ loans. The accuracy of the Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Context: From a population of 42 students that withdrew officially during a term, we tested 5 students and noted that all 5 were not reported timely. Recommendation: We recommend that the College put procedures in place to ensure that any changes in student enrollments are properly tracked and updated to the NSLDS. Management Response: When the Registrar’s Office is notified of a student’s withdrawal (official or unofficial), within 24 hours the student’s record in the National Student Clearinghouse will be manually flagged as withdrawn with their last date of attendance. Party responsible: Sherry A. Phelps Office phone: 540-828-5313 Email address: sphelps2@bridgewater.edu Expected date of correction: This problem was corrected on 6/27/2024 when it was brought to my attention and since that date the required information has been correctly reported directly into the National Student Clearinghouse within 24 hours of the date of determination of a student’s withdraw from the college.

View Audit 350883

Finding 544078 (2024-001)

Material Weakness 2024

Gaudenzia Inc.

PA

Allowable Costs / Cost Principles Eligibility Matching / Level of Effort / Earmarking

2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: HOME Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Agencies: City of Philadelphia, Redevelopment Authority: Venango – Loan Thompson Street – Loan County of S...

2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: HOME Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Agencies: City of Philadelphia, Redevelopment Authority: Venango – Loan Thompson Street – Loan County of Schuylkill - Home Investment Partnerships and Housing Trust Funds Programs: Fountain Springs - Loan Mayor and City of Baltimore: Baltimore Housing - Park Heights Women and Children - Loan Condition: As part of the eligibility requirement for the HOME Investment Partnership program, we are required to review files of client residents who were provided residential drug and alcohol treatment services at the Organization’s locations in Venango (Re-Entry), Fountain Springs, Thompson Street, and Park Heights Women and Children. We sampled a total of 40 resident clients at these four locations covered by HOME loans and requested documentation within client resident files, including proof of residency, proof of income (low income or homeless), and lease or housing agreement (depending on program requirements). Of the 40 resident client files reviewed, management was unable to provide any proof of income or determination of homelessness or residency for 24 files. Recommendation: We recommend that management adopt policies and procedures including both the communication of compliance requirements between staff and locations and the development of documentation and processes to assist in how income eligibility is determined. This includes management developing certain income verification documents that can be used as part of the intake process for determining the eligibility of the residential client. In addition, process will need to be developed for the redetermination of income if a residential client has lived over a year at a particular location. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Gaudenzia, Inc believes that had the requisite documentation been completed, it would have been in compliance with the low-income compliance requirement as the referral sources that were used to place the clients in the program are all coming from CBH as well as other MCO funded partners. These referral sources are typically Medicaid clients and are typically well below the low-income requirement thresholds. Action taken in response to finding: Gaudenzia, Inc has incorporated existing low-income eligibility procedures to the Project Home Loans program sites to be in full compliance of the eligibility requirements. These procedures will be reinforced within our programs to ensure the requisite documentation is in place. Name of the contact person responsible for corrective action: Nikant Ohri, Chief Financial Officer, nikant.ohri@guadenzia.org (610) 860-2061 Planned completion date for corrective action plan: June 30, 2025

View Audit 350881

Finding 542030 (2024-002)

Significant Deficiency 2024

University of Pikeville

KY

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions

Federal Program: U.S. Department of Education Federal Direct Loan Program, Federal Assistance Listing 84.268 Criteria: The University is required to comply with 36 CFR Section 685.309(b). Condition: During our testing of 40 students for eligibility, we noted three students in which the students' ...

Federal Program: U.S. Department of Education Federal Direct Loan Program, Federal Assistance Listing 84.268 Criteria: The University is required to comply with 36 CFR Section 685.309(b). Condition: During our testing of 40 students for eligibility, we noted three students in which the students' status change was not timely reported to the National Student Loan Database System (NSLDS). Corrective Actions Taken or Planned: For the year ended June 30, 2024, three students were reported late to NSLDS. Each student, after being identified, were then reported to NSLDS with the correct status and date. The Office of Institutional Research will work with the Registrar’s Office to ensure that students are reported in a timely manner. The Director of Institutional Research has provided the following steps that will be taken when a student is reported as withdrawn: 1. View the student's transcript in Ellucian to see if he/she withdrew or is back-dated as never enrolling. 2. Update Excel file for the term enrollment accordingly. 3. Update National Student Clearinghouse (NSC) file that will be submitted on the next due date. 4. Manually update the student's enrollment in National Student Clearinghouse 5. Manually update the student's enrollment in NSLDS Name of Responsible Person: Daniel Donner, Director of Financial Aid Completion Date: August 13, 2024

View Audit 350857

Finding 542010 (2024-005)

Significant Deficiency 2024

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.306 § 200.403

Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of match expenditures, testing noted 5.15 hours identified as Medicaid hours for one employee were not removed from...

Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of match expenditures, testing noted 5.15 hours identified as Medicaid hours for one employee were not removed from the employee’s total hours when calculating the amount of match for the federal program. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could claim as match disallowed costs under the federal award and would not be able to detect and correct noncompliance in a timely manner. The employee’s Medicaid hours were not properly included within a revenues report due to the employee’s provider number not being included within the report parameters. Responsible Individuals: CEO (Dan Ries) Corrective Action Plan: CEO will double check and confirm that all revenue reports run have data for the correct staff to ensure that the accurate information is being used to calculate match hours. Anticipated Completion Date: September 2024.

View Audit 350836 Questioned Costs: $1

Finding 542009 (2024-004)

Significant Deficiency 2024

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.430

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.696 Program Name: Certified Community Behavior Health Clinic Expansion Grants Finding Summary: During testing of expenditures, the following was identified: a) ClickTime timecard, which trac...

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.696 Program Name: Certified Community Behavior Health Clinic Expansion Grants Finding Summary: During testing of expenditures, the following was identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (1 instance). b) Calculation errors for expenses allocated to the grant (3 instances). c) Employee tracked 2.7 hours under the federal program and a nonfederal program line in ClickTime (1 instance) causing it to be double counted. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. An employee entered 8 hours of PTO into ClickTime for two days each; however, the employee was only paid for 4 hours of PTO for each day. The calculation errors were due to the use of a wrong employee’s allocation percentage and a keying error for payroll expenses for an employee. The secondary review of the employee ClickTime timecards did not identify the incorrectly tracked hours and double tracked time. Also, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. Responsible Individuals: Project Directors (Rebecca McCrackin, Missy Martini), Project Accounts Manager (Marsha Bomgaars) and CEO (Dan Ries) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare and reconcile all ClickTime reports with payroll reports using an Excel spreadsheet to identify discrepancies and to ensure the ClickTime timecards and the payroll registers match and all hours are accurately reported. Anticipated Completion Date: September 2024.

View Audit 350836 Questioned Costs: $1

Finding 541991 (2024-001)

Significant Deficiency 2024

Bridgehampton Union Free School District

NY

Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.430

2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires...

2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee's compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District had not prepared periodic certification equivalents for all employees. Planned Corrective Action: The District will monitor procedures to ensure that documentation to support salaries and wages charged to federal awards is in a format that complies with the requirements of the Uniform Guidance Subpart E, 2 CFR §200.430. Responsible Contact Person: Peter Daly Interim School Business Administrator Bridgehampton Union Free School District 2685 Montauk Highway Bridgehampton, New York 11932 Anticipated Completion Date: June 30, 2025.

View Audit 350800

Finding 541990 (2024-004)

Significant Deficiency 2024

College Unbound

RI

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: Previously, this was an ancillary work task for a staff member in a different department. CU has since hired an experienced Registrar and ...

Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: Previously, this was an ancillary work task for a staff member in a different department. CU has since hired an experienced Registrar and begun training an Associate Registrar. The dedicated department now updates Clearinghouse on the required monthly basis. All previous records have been corrected. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Mark Hartonchik, CFO

View Audit 350797

Finding 541988 (2024-002)

Significant Deficiency 2024

College Unbound

RI

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: These findings are from Fall 2023. College Unbound has corrected this as of Spring 2024. The new practice, start...

Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2024 Corrective Action Plan: These findings are from Fall 2023. College Unbound has corrected this as of Spring 2024. The new practice, started February 2024, is to run a weekly report every Friday of disbursements made during that week. Every student on that disbursement list receives and email that a disbursement has been made and instructions how to review their account in their online student portal. We have been replicating this process for over 12 months now and will continue to do so in the future. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Mark Hartonchik, CFO

View Audit 350797

Finding 541987 (2024-003)

Significant Deficiency 2024

College Unbound

RI

Questioned Costs Matching / Level of Effort / Earmarking Student Financial Aid

Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2024 Corrective Action Plan: This finding was the result of failure to fully...

Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2024 Corrective Action Plan: This finding was the result of failure to fully execute a professional judgment (PJ) calculation. We processed a PJ on the now-closed FAA access but failed to import the updated EFC into our system. As FAA is now closed, we cannot show the updated EFC. College Unbound does regular monthly checks to ensure that no student exceeds cost of attendance or need. This one was a PJ done sloppily. Timeline for Implementation of Corrective Action Plan: Completed Contact Person: Mark Hartonchik, CFO

View Audit 350797 Questioned Costs: $1

Finding 541975 (2024-002)

Significant Deficiency 2024

Honey Lake Valley Resource Conservation District

CA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: At the March 27th, 2025 Board Meeting, the District addressed the issue of missing signatures on checks. As a result, the following actions were agreed upon: • The District Manager will ...

Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: At the March 27th, 2025 Board Meeting, the District addressed the issue of missing signatures on checks. As a result, the following actions were agreed upon: • The District Manager will comply with District Policy 3140 at all times. • When possible, Board Members will sign checks at regularly scheduled Board meetings. • If waiting for the next meeting is not feasible, the District will implement the following internal control process, documented in an internal Standard Operating Procedure (SOP): 1. The District Manager will initiate payment and draft the check. 2. The Bookkeeper will log the relevant information into the internal Check Control Log. 3. The District Manager will contact the Board to obtain the necessary signatures. 4. Once signed, the District Manager will notify the Bookkeeper of the signatories, who will update the Check Control Log with their names or initials. 5. The Bookkeeper will verify the check and signatories once the check has cleared but before it is uploaded to the QuickBooks General Ledger. Anticipated Completion Date: June 30, 2025

View Audit 350779

Finding 541974 (2024-001)

Significant Deficiency 2024

Honey Lake Valley Resource Conservation District

CA

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

Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: The District has implemented the recommended action, requiring that all internal billing worksheets be reconciled to the QuickBooks general ledger prior to final District Manager approv...

Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: The District has implemented the recommended action, requiring that all internal billing worksheets be reconciled to the QuickBooks general ledger prior to final District Manager approval. However, to ensure proper documentation, the District will develop and implement a check-off spreadsheet to track when this reconciliation has been completed for each payment request. Additionally, an internal Standard Operating Procedure (SOP) for Billing Worksheet – General Ledger reconciliation will be created to formalize and document the process, ensuring it is retained. Anticipated Completion Date: June 30, 2025

View Audit 350779

Finding 541971 (2024-002)

Significant Deficiency 2024

United Tribes Technical College

ND

Matching / Level of Effort / Earmarking

Recommendation: We recommend the College set up a debt reserve fund in accordance with the loan agreement. Action Taken: The College met with the lending agency regarding debt reserve fund account and reporting process. A debt reserve account has been established in accordance with the loan agreemen...

Recommendation: We recommend the College set up a debt reserve fund in accordance with the loan agreement. Action Taken: The College met with the lending agency regarding debt reserve fund account and reporting process. A debt reserve account has been established in accordance with the loan agreement.

View Audit 350766

Finding 541968 (2024-001)

Significant Deficiency 2024

Boston Public Health Commission

MA

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management implemented an additional control that any submitted workbook or invoice that is changed by an awarding agency before payment is made, must be thoroughly reviewed and reconciled prior to authorizing the workbook or invoice for payment.

View Audit 350763 Questioned Costs: $1

Finding 541966 (2024-035)

Significant Deficiency 2024

State of Louisiana

LA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Dear Mr. Waguespack: The Governor’s Office of Homeland Security and Emergency Preparedness (GOHSEP) hereby provides our official response to the fiscal year 2024 single audit finding and follow up to the FY23 finding. As requested, please see the details of our response below: • This response is p...

Dear Mr. Waguespack: The Governor’s Office of Homeland Security and Emergency Preparedness (GOHSEP) hereby provides our official response to the fiscal year 2024 single audit finding and follow up to the FY23 finding. As requested, please see the details of our response below: • This response is provided for the finding, “Noncompliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA).” • GOHSEP concurs in part with the individual finding and recommendation: o This Louisiana Legislative Auditor (LLA) FY24 audit covered a sample of Flood Mitigation Assistance (FMA) and Hazard Mitigation Grant Program (HMGP) projects. o The finding provided that GOHSEP entered four (4) HMGP and twelve (12) FMA subawards into FSRS greater than 30 days after the FEMA award was made. • The FY24 HMGP projects that were selected for audit were the same projects that were selected by LLA for the FY23 audit follow up. • This essentially creates a duplicative finding on these projects • Additionally, those HMGP FSRS entries were entered on January 23, 2024, which pre-dated the FY23 finding and our corrective actions being implemented during calendar year 2024. Please reference our FY23 Single Audit Report Response for those details. Since these projects were already entered by the time of last year’s finding, there is nothing further that can be done to correct these project entries. • Of the FY24 FMA projects that were selected for audit, two of them were also selected by LLA for the FY23 audit follow-up, creating a duplicative finding. • The remaining 10 FMA projects in question were all entered in calendar year 2024 as part of our FY23 corrective action plan. • GOHSEP concedes that the questioned FSRS entries were not made in accordance with the portion of 2 CFR Part 170, Appendix A(I)(a), which requires the entries to be made by the end of the month following the month in which the obligation was made. • As discussed with LLA staff, GOHSEP encountered issues with staff having limited access to all necessary grants in FSRS. • Also as previously discussed, GOHSEP Hazard Mitigation Assistance (HMA) was unable to use the FFATA reporting feature in GOHSEP Grants (system of record) to import the data into FSRS. o GOHSEP concurs in part with LLA’s recommendation that GOHSEP should strengthen internal controls to ensure that appropriate personnel have the necessary access to FSRS and are timely entering the required award information for FFATA reporting in accordance with federal requirements. • Our Corrective Action Plan from FY23 is being implemented; however, there are still issues beyond our control in the FSRS system, as far as permissions for more than one staff, as well as the report from GOHSEP Grants working as it should. • We recognize there were still some entries made greater than 30 days after award, and we are working to correct the parts of the process that aren’t working as efficiently as it should. • FSRS is being retired this Spring, and the process for the new system entry will require an entirely new implementation plan. • Corrective Action Plan: o Persons responsible for corrective action: • Sandra D. Gaspard (Assistant Director, HMA) • Jeffrey Giering (Executive Officer, HMA) o Corrective Action Planned: • GOHSEP HMA will ensure that the FEMA reports that are necessary for FSRS entry are being received by the correct staff in a timely manner, and ensure the data is checked and entered more than once monthly. • GOHSEP HMA will continue working with GOHSEP IT and with the GOHSEP Grants vendor to ensure that the FFATA reporting function in the system becomes functional and continues working correctly. This will enable HMA staff to more accurately and efficiently enter the required obligation information into FSRS, versus a manual process. o Anticipated Completion Date: • 90-Days We appreciate your assistance with this matter. If you need additional information, please contact Sandra D. Gaspard, Assistant Director, HMA at 985-969-0410 or via email at Sandra.Dugas@la.gov.

View Audit 350759

Finding 541964 (2024-030)

Significant Deficiency 2024

State of Louisiana

LA

Questioned Costs Matching / Level of Effort / Earmarking § 200.306

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Noncompliance with Medicaid Federal Matching and Reporting Requirements Related to...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Noncompliance with Medicaid Federal Matching and Reporting Requirements Related to a Means of Financing Reallocation. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Noncompliance with Medicaid Federal Matching and Reporting Requirements Related to a Means of Financing Reallocation Recommendation: LDH management should strengthen the system of internal controls over preparation and review of the quarterly CMS-64 reports to ensure expenditures are accurately reported and that the required amount of state and/or local funds are available and used to match the state’s allowable expenditures. LDH Response: LDH Management concurs that the reallocation of the Medicaid expenditures that include federal and state shares should have been excluded from the June 30, 2024 CMS64 report. LDH Management recognizes its responsibility to accurately report financial data, but also acknowledges that staffing shortages and inadequate/insufficient training resulted in less-than-ideal reporting conditions creating limited knowledge and experience with the data and reporting requirements and time for thorough reviews Corrective Action Plan: LDH Fiscal Management has already taken steps to aggressively work towards improving staffing knowledge and skills by way of securing the services of a vendor who offers CMS64 support and training for federal reporting requirements. In addition, LDH Fiscal is working with the vendor to develop a comprehensive training/development plan for staff responsible for CMS64 reporting and establish collaboration with Human Resources to address staffing efforts. The corrective action plan completion date to address this compliance was effective immediately upon notification of the error, recognizing that this will be an ongoing corrective action plan of monitoring as LDH Fiscal works to create a culture of continuous improvement. Clinton Summer, Accountant Manager 4/Comptroller for Medicaid Financial Reporting and Helen Harris, Deputy Undersecretary 2/Fiscal Director, are responsible for the execution and implementation of this corrective action. You may contact Clinton Summers, Accountant Manager 4 at (225) 342-5701 or via email at Clinton.Summers@la.gov or Helen Harris, LDH Fiscal Director, at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

View Audit 350759 Questioned Costs: $1

Finding 541962 (2024-028)

Significant Deficiency 2024

State of Louisiana

LA

Questioned Costs Matching / Level of Effort / Earmarking

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 7, 2025 regarding a reportable audit finding related to Noncompliance with Disproportionate Share Hospital Payments. LDH appreciates the o...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 7, 2025 regarding a reportable audit finding related to Noncompliance with Disproportionate Share Hospital Payments. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Noncompliance with Disproportionate Share Hospital Payments Recommendation: LDH should ensure an adequate review of the tracking spreadsheet to verify that all federal payments are included and to prevent the department from exceeding the federal DSH allotment in the future. LDH Response: LDH concurs with the finding of noncompliance with 2016 disproportionate share hospital payments as the global DSH allotment was exceeded for that FFY. The department anticipated a full recoupment from one of our facilities upon completion of the original DSH audit report, however, upon completion of an addendum, the facility submitted additional information which reduced their liability and resulted in an overpayment. Corrective Action: LLA has identified $4,225,716 of total computable payments made in excess of the global DSH allotment for FFY 2016. The department will recoup funds from the facility that was overpaid and return the FFP portion of that overpayment to CMS. The Department will also return the FFP portion of the remaining amount that was payments in excess of the global allotment to CMS. In the future, LDH will ensure an adequate review of the tracking spreadsheet to verify that all federal payments are included to prevent the department from exceeding the federal DSH allotment. Any adjustments resulting from potential overpayments which would increase the available DSH state allotment cap shall not be recognized until recoupment is finalized and complete. You may contact Kimberly Sullivan, Medicaid Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Jackie Cummings, Medicaid Program Manager 4 at (225) 342-7505 or via email at Jackie.Cummings2@la.gov with any questions about this matter.

View Audit 350759 Questioned Costs: $1

Finding 541956 (2024-022)

Significant Deficiency 2024

State of Louisiana

LA

Questioned Costs Matching / Level of Effort / Earmarking § 200.306

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Inadequate Controls over and Noncompliance with Matching and Reporting Requirement...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Inadequate Controls over and Noncompliance with Matching and Reporting Requirements Related to the Cost Share Process. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over and Noncompliance with Matching and Reporting Requirements Related to the Cost Share Process Recommendation: LDH management should ensure the cost share tables are appropriately updated for all periods during the fiscal year. In addition, LDH should strengthen controls over preparation and review of the quarterly CMS-64 federal expenditure reports to ensure that the appropriate federal match is applied to qualifying expenditures and the required amount of state and/or local funds are available and used to match the state’s allowable expenditures. LDH Response: LDH management concurs that the cost share tables were not updated for all periods during the fiscal year in LaGov. Although the rates in LaGov did not impact accurate federal reporting in MBES, we recognize that for comparison and accuracy, the rates should have been verified in both instances. Our expenditure reporting to CMS via MBES is entered based on total expenditures as MBES calculates the FMAP automatically. However, we are implementing additional controls in our SOPs that will ensure the FMAP information in LaGov remains current. Corrective Action Plan: The tables have been updated in the LaGov system as of January 2025 and we are currently adding a task to quarterly checklist to ensure the rates are aligned between LaGov and MBES. In addition, we are exploring the possibilities to update queries and reports, where possible, to further strengthen reporting accuracy by automatically tying to the FMAP information in LaGov so queries and reports can automatically calculate the appropriate federal and state match which will also avoid any potential discrepancy that may arise from manual intervention/calculations. This corrective action plan to address the feasibility of updating queries and reports is ongoing, but an anticipated assessment date is May 30, 2025. Clinton Summer, Accountant Manager 4/Comptroller for Medicaid Financial Reporting and Helen Harris, Deputy Undersecretary 2/Fiscal Director, are responsible for the execution and implementation of this corrective action. You may contact Clinton Summers, Accountant Manager 4 at (225) 342-5701 or via email at Clinton.Summers@la.gov or Helen Harris, LDH Fiscal Director, at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

View Audit 350759 Questioned Costs: $1

Finding 541886 (2024-024)

Significant Deficiency 2024

State of Louisiana

LA

Matching / Level of Effort / Earmarking § 200.302 § 200.328 § 200.329

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Inadequate Controls over Reporting and Matching Federal Compliance Requirements fo...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Inadequate Controls over Reporting and Matching Federal Compliance Requirements for the Medicaid and Children’s Health Insurance Programs. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over Reporting and Matching Federal Compliance Requirements for the Medicaid and Children’s Health Insurance Programs Recommendation: LDH management should strengthen controls over preparation and review of the quarterly federal expenditure reports and quarterly adjustments to ensure federal expenditures are accurately reported. In addition, LDH management should incorporate a reconciliation of federal expenditures in the financial statements to federal expenditures reported to CMS. LDH Response: LDH Management concurs that controls over preparation and review of the quarterly federal report were insufficient and should be strengthened. LDH Management recognizes its responsibility to accurately report financial data, while also acknowledging that staffing shortages and inadequate/insufficient training resulted in less-than-ideal reporting conditions creating limited knowledge and experience with the data and reporting requirements and adequate time for thorough reviews for this reporting year. Corrective Action Plan: LDH Fiscal Management in collaboration with our contracted consultants are working towards updating standard operating procedures to include the review process as well as training for the preparer and reviewers of the work. Also, a development of a reconciliation to capture all reporting in MBES in comparison to LaGov is being created. The corrective action plan completion date to address this is anticipated for completion during the April 2025 federal reporting period. Clinton Summer, Accountant Manager 4/Comptroller for Medicaid Financial Reporting and Helen Harris, Deputy Undersecretary 2/Fiscal Director, are responsible for the execution and implementation of this corrective action. You may contact Clinton Summers, Accountant Manager 4 at (225) 342-5701 or via email at Clinton.Summers@la.gov or Helen Harris, LDH Fiscal Director, at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

View Audit 350759

Finding 541883 (2024-020)

Significant Deficiency 2024

State of Louisiana

LA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) Child Welfare (CW) is in receipt of the audit findings identified as Control Weakness over SSBG Expenditures. DCFS concurs with the finding and is committed to minimizing errors and ensuring documentation practices support o...

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) Child Welfare (CW) is in receipt of the audit findings identified as Control Weakness over SSBG Expenditures. DCFS concurs with the finding and is committed to minimizing errors and ensuring documentation practices support our efforts for accuracy and compliance. DCFS will develop and implement training to ensure that instruction provided regarding the maintenance of TIPS records and payments will achieve compliance to the extent possible. DCFS CW Training and Foster Care will create a short refresher video course on policies and procedures relating to payment protocols to be made available to child welfare staff. The anticipated completion date will be June 30, 2025. Additionally, DCFS CW has adopted the use of DocuSign for TIPS forms which allows for a more streamlined process for signatures and supporting documentation to be uploaded. A short video course providing instruction on completing and submitting TIPS forms for reimbursement using the DocuSign platform is available to child welfare statewide. Management will reiterate staff to refer to this training. Should any additional information be required, please contact Renee M. Spell at (337) 250-1690 or Renee.Spell.DCFS@LA.GOV.

View Audit 350759

Finding 541877 (2024-032)

Significant Deficiency 2024

State of Louisiana

LA

Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.328 § 200.329

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 3, 2025 regarding a reportable audit finding related to the Office of Public Health (OPH) – Inadequate Controls over and Noncompliance wit...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 3, 2025 regarding a reportable audit finding related to the Office of Public Health (OPH) – Inadequate Controls over and Noncompliance with Federal Financial Reporting. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over and Noncompliance with Federal Financial Reporting Recommendation: OPH should design and implement controls to ensure all information contained in the financial reports submitted to Federal agencies is accurate, current, and complete for the reporting period covered under the report. LDH Response: LDH Fiscal Management recognizes its responsibility to accurately report financial data, however, LDH Fiscal Management does not concur with the finding of Inadequate Controls over and Noncompliance with Federal Financial Reporting (FFR) due to immateriality of the questioned expenses. The expenses in question reported on the Federal Financial Report were eligible grant expenses for this award. LDH Fiscal understood the expenses in question to be related to the same award that was ending 6/30/24, but received a No Cost Extension through 12/31/2024. After consulting with the grantor on this matter, the grantor conveyed that reporting these eligible expenditures earlier than the No Cost Extension date was not a material concern and would not require a revised FFR for this period, as the main concern is that they were eligible expenses and would be included in the final FFR. Total expenses in question ($142,568) represent approximately .3% of the cumulative expenses reported on the Federal Financial Report ($42M) as of 06/30/2024; therefore, the stance of LDH is the amount in question is immaterial and does not misstate the Federal Financial Report. Corrective Action Plan: Procedures and internal training currently exist for fiscal team members on completing Federal Financial Reports. A corrective action plan to reiterate and reinforce the understanding of various reporting periods to include No Cost Extension and liquidation periods to the preparers and reviewers of the FFR’s to mitigate this occurrence was implemented immediately. Quintesah Syas, Accountant Manager 4/Comptroller within the LDH Fiscal Office for Office of Public Health Financial Reporting and Helen Harris, Deputy Undersecretary 2/LDH Fiscal Director are responsible for the execution and implementation of this corrective action and may be contacted with any questions about this matter. You may contact Quintesah Syas Accountant Manager 4/Comptroller, within the LDH Fiscal Office for Office of Public Health Financial Reporting at (225) 342-9333 or via email at Quintesah.Syas@la.gov, or Helen Harris), Deputy Undersecretary 2/LDH Fiscal Director at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

View Audit 350759

Corrective Action Plans

Filters