Corrective Action Plans

2022-008 N. Special Tests and ProvisionsEducation Stabilization Fund CFDA #84.425Material Weakness in Internal Control over Compliance and Material Instance of NoncomplianceFinding Summary: During the course of the engagement, it was identified that the School didnot satisfy the requirements of 2 CFR 656.40 through 2 CFR 656.41. The School did not ensure proper inclusion of prevailing wage rate clauses were included in a construction contract and also did not obtain proper support to ensure required certified payrolls were submitted.Corrective Action Plan: The School will review internal controls surrounding required contract language and documentation supporting certified payroll reports are obtained from contractor.Anticipated Completion Date: June 30, 2023

Finding 2022-005 ReportingThe Corporation management agreed with the finding. As of August 15, 2023, the Corporation will remove any individual submissions from the general submission and reconcile the general submission to the supporting documentation less these individual submissions. The Corporation does not expect to receive any further funding from the ARP or PRF and has no further reporting requirements under this grant.Responsible Personnel include Harley McCoige, Controller, Cortney Couture, Director of Accounting, and Samantha Pratt, Director of Internal audit.

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

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

To ensure the charging of indirect costs to federal programs are at the elected de minimis amount of 10% and in the correct fiscal period, the UWGC Chief Financial Officer or the UWGC Senior Director of Finance will perform a secondary review of the calculation prepared by the Finance Manager. The review will take place prior to the final completion of the report to ensure that Federal funds are reported in the correct time period as well.

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

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

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.

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.

Dear Mr. Waguespack,Thank you for the opportunity to respond to your office's finding related to special tests and provisions requirements. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff and we concur with the finding.Recommendation:Management should continue to provide training for time and effort certifications.Response with Corrective Action Plan:LSUHSC-S will continue to offer training classes and educational meetings to address the Federal requirements and ensure compliance. The training classes include one-on-one departmental meetings held by the Office of Sponsored Programs on new awards, Department Business Manager and Administrative Staff monthly meetings and research personnel time and effort educational sessions.Name of Contact(s) Responsible for Action PlanAnnella Nelson, Assistant Vice Chancellor for Research DevelopmentValarie White, Director, Office of Sponsored Programs (OSP)William Haacker, Assistant Director of Grants AccountingJen Katzman, Assistant Vice Chancellor for Administration and FinanceAnticipated Completion Date: ContinuousRecommendation:Management should also utilize the time and effort certifications and updated PER-3 forms to monitor changes in effort for key personnel and verify that prior written approval is obtained from the federal grantor for changes that exceed the thresholds set in federal regulations.Response with Corrective Action Plan:LSUHSC-S will use both the time & effort certifications and personnel status change forms (PER-3s) to monitor effort percentages on federal grants. The monitoring review will include the departmental business staff and Principal Investigators (Pls).The new grant management software, Cayuse, that should be implemented now in FY2024, could be a source for the automation of time & effort tracking; however, until available, management is reviewing additional avenues to address this institutional internal control to include the re-initiation of the master tracking document reflecting the award's original personnel effort with changes as approved through the internal PER-3 form and/or written approval from federal grantor as necessary.Regarding prior approval for effort changes, OSP is the institution office of record that seeks written approval from the federal grantor if the level of effort is reduced by 25% or more for the PI or any senior/key personnel named in the notice of award per federal requirements. OSP is communicating with the Departmental PIs and Business Managers regarding effort changes throughout the grant year and reviews again with the PIs and Business Managers during annual progress reporting.With the implemented processes, LSUHSC-S should be able to ensure that the time & effort reporting during the grant year is reflective of the award document or if any approved changes from the federal grantor is required prior to annual progress report completion.Anticipated Completion Date: ContinuousName of Contact (s) Responsible for Action Plan:Sheila Faour, Chief Financial Officer, Business and ReimbursementsAnnella Nelson, Assistant Vice Chancellor for Research DevelopmentValarie White, Director, Office of Sponsored ProgramsWilliam Haacker, Assistant Director of Grants AccountingJen Katzman, Assistant Vice Chancellor for Administration and FinanceIf you have questions or need additional information, please contact me at (318) 675-5230 or via email at cindy.rives@lsuhs.edu.

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.

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

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

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

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

REFERENCE: 2022-017 ? Special Tests and Provisions ? Disbursements to or on Behalf of StudentsSFA Cluster (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 send loan notifications to 2 of 28 students selected for disbursement testing for direct loans.Corrective Action Plan: Compliance will be verified through internal audit of student disbursements. A sample of disbursements will be checked for proper notifications on periodic basis throughout the semester.Person Responsible: James Younger, Dean of Financial Services and DevelopmentExpected Completion: April 2023

REFERENCE: 2022-001 ? Special Tests and Provisions ? Disbursements to or on Behalf of StudentsStudent Financial Assistance Cluster (Assistance listing No. 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 evidence of whether the quality assurance system was operating effectively during the fiscal year ended June 30, 2022.Corrective Action Plan: This finding was corrected by June 30, 2022. In January 2021 the institution updated the Financial Aid Department Policy and Procedure Manual to include a section that address quality assurance oversight. The Quality Assurance Plan developed includes the following: reports loan records, disbursements, and adjustments to disbursements correctly to the Common Origination Disbursement system; disburses and returns loan funds in accordance with regulatory requirements; disburses the correct loan amount to the correct student; completes monthly reconciliation and Program Year Closeout. Program will be reviewed annually and updated accordingly by FAS and GSC Management. Compliance with the quality assurance policy is monitored through the reconciliation process which was implemented in June 2022.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health ScienceCompletion: June 2022

REFERENCE: 2022-002 ? Special Tests and Provisions ? Borrower Data and Reconciliation (Direct Loan)Student Financial Assistance Cluster (Assistance Listing No. 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 perform the direct loan monthlyreconciliations for FY22.Corrective Action Plan: Good Samaritan implemented 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

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

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

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

REFERENCE: 2022-011 ? Special Tests and Provisions ? Key PersonnelResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, level of effort is reviewed and certified by PI?s.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerCompletion: September 2022

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

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

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