Corrective Action Plans

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

Finding 541876 (2024-019)

Significant Deficiency 2024

State of Louisiana

LA

Student Financial Aid Cash Management Matching / Level of Effort / Earmarking

Dear Mr. Waguespack, The University of Louisiana at Monroe acknowledges receipt of the audit finding related to Noncompliance and Inadequate Controls over Direct Loan Monthly Reconciliations. We appreciate the opportunity to respond and outline the corrective actions the university has taken or pla...

Dear Mr. Waguespack, The University of Louisiana at Monroe acknowledges receipt of the audit finding related to Noncompliance and Inadequate Controls over Direct Loan Monthly Reconciliations. We appreciate the opportunity to respond and outline the corrective actions the university has taken or plans to implement to address the issue. Corrective Action Plan: The Financial Aid Office will be reaching out to Common Origination and Disbursement (COD) for assistance in correcting this issue with the monthly account statement. The discrepancies were identified each month, however the reason for the discrepancy and how we corrected the error was not documented. We will adjust our policies and procedures to add these steps to the reconciliation process in addition to the secondary reconciliation of the account statement that will be completed. To address this issue, the university has implemented or is in the process of implementing the following corrective actions: 1. Action Taken or Planned: • Work with COD to correct issues with accessing monthly account statements. • Implement a process to add a secondary monthly reconciliation of account statements, in addition to the current method of reconciling each month using the annual report. This will ensure that no loan discrepancy is missed in the reconciliation. • Train the new Functional Analyst how to document discrepancies on the monthly report. • Add a designated column to the discrepancy list identifying the exact amount in question and the reason why it does not match COD. • Send response emails documenting reconciliation has been reviewed, issues have been cleared, and how each issue was cleared. 2. Implementation Timeline: April 1, 2025 3. Responsible Party: Various members of the Financial Aid team. Director Marla Herrington and Functional Analyst Lacie Campbell will be responsible for the implementation and execution of the corrective action. 4. Ongoing Monitoring and Compliance: When the Director sends the email confirming the corrections have been completed, the Director will copy the Associate Director of Customer Service, Erica Hopko, on the email alerting her to verify that all components have been addressed and that the discrepancy has been clearly explained. The university is committed to maintaining compliance with all applicable regulations and strengthening internal controls to ensure the integrity of our financial aid processes. Please do not hesitate to reach out if any further clarification is needed.

View Audit 350759

Finding 541872 (2024-015)

Significant Deficiency 2024

State of Louisiana

LA

Reporting Student Financial Aid Special Tests & Provisions

We have reviewed the audit findings from your letter dated January 24, 2025, and appreciate the time and effort of your staff in assisting us in improving our operations. Please find our response to the finding below. Finding: Inaccurate Reporting of Student Enrollment Status Management concurs wi...

We have reviewed the audit findings from your letter dated January 24, 2025, and appreciate the time and effort of your staff in assisting us in improving our operations. Please find our response to the finding below. Finding: Inaccurate Reporting of Student Enrollment Status Management concurs with the finding noted in the report. Corrective Actions: 1. The Registrar's Office created a new National Student Clearinghouse (NSC) reporting schedule to ensure compliance. Completion Date: August 30, 2024 2. The new NSC reporting schedule will be published on the Registrar's website for accountability and information purposes. Estimated Completion Date: February 15, 2025 3. Programming changes to PeopleSoft will be completed whenever new degree programs are created to ensure that students are reported correctly to the NSC. The Registrar's Office will update its policies and procedures, as well as NSC reporting instructions based on these changes. This will ensure that students are reported correctly to the NSC. Estimated Completion Date: April 1, 2025 4. The Office of Financial Aid granted access to National Student Loan Data System (NSLDS) enrollment corrections to the Registrar’s Office. Completion Date: January 27, 2025 5. The Registrar's Office will create new policy and procedures to manually correct NSLDS enrollment data for any enrollment transactions (retroactive drops or withdrawals) taking place after the final NSC submission for each term that has been sent. Estimated Completion Date: May 16, 2025 Responsible Personnel: University Registrar If you have any additional questions or concerns, please do not hesitate to contact me.

View Audit 350759

Finding 541871 (2024-014)

Significant Deficiency 2024

State of Louisiana

LA

Cash Management Reporting Student Financial Aid

We have reviewed the audit finding from your letter dated January 14, 2025, and appreciate the time and effort of your staff in assisting us in improving our operations. Please find our response to the finding below. Finding: Control Weakness over Direct Loans Monthly Reconciliations Management co...

We have reviewed the audit finding from your letter dated January 14, 2025, and appreciate the time and effort of your staff in assisting us in improving our operations. Please find our response to the finding below. Finding: Control Weakness over Direct Loans Monthly Reconciliations Management concurs in part with the finding noted in the report. Response: LSUHSC-NO is committed to continued fiscal responsibility in all facets of our University, including our participation in, and administration of, the Federal Direct Student Loans program. As evidence of our commitment, LSUHSC-NO has a three pronged reconciliation approach when administering these federal dollars: 1) the Office of Financial Aid (OFA) completes a monthly reconciliation between loan disbursements recorded in PeopleSoft and the federal Common Origination & Disbursement (COD) system, 2) with each drawdown request from the OFA, the Sponsored Project office compares the "Net Draws" in G6 to "Cash Receipts" reported in COD to ensure the drawdown of federal funds is appropriate, and 3) the Accounting Services office completes a monthly reconciliation whereby the activity in the federal systems (G6 and COD) are reconciled to the activity in our ledgers and sub-ledgers. The noted finding is in relation to the reconciliations performed by our Accounting Services office. Due to staffing transitions in LSUHSC-NO's Office of Financial Aid, there was a delay in the completion of the monthly reconciliations for the months of July 2023 - September 2023; therefore, these reconciliations were not finalized until November 2023. LSUHSC-NO believes that it has fully complied with the requisite federal regulations and has exercised appropriate controls over the administration of these federal dollars. The Federal regulations state that "schools must, on a monthly basis, reconcile institutional records with the Federal Direct Student Loan Funds received and disbursement records submitted ...” 34 CFR 685.300(b)(5). The regulations do not specify when monthly reconciliations must occur. Additionally, it is of note that the monthly reconciliations tied out exactly and contained no errors. Therefore LSUHSC-NO believes that its monthly reconciliations were in compliance with the regulations as written. However, we do recognize that timely reconciliations are an important control feature and our direct loan reconciliation procedures should be revised to ensure that the reconciliations are prepared and reviewed timely. Corrective Action: 1. Accounting Services will modify its procedures governing the reconciliation of federal direct loans to ensure that the reconciliations are prepared and reviewed within 45 days of month end. Responsible Personnel: Executive Director of Accounting Services Anticipated Completion Date: January 31, 2025 If you have any additional questions or concerns, please do not hesitate to contact me.

View Audit 350759

Finding 541866 (2024-016)

Significant Deficiency 2024

State of Louisiana

LA

Student Financial Aid Reporting Special Tests & Provisions

Dear Mr. Waguespack: Thank you for the opportunity to offer the University’s response to the referenced finding. FINDING: Control Weaknesses over and noncompliance with Enrollment Reporting RESPONSE: Southern University - Baton Rouge (SUBR) concurs with the above noted finding. Management concur...

Dear Mr. Waguespack: Thank you for the opportunity to offer the University’s response to the referenced finding. FINDING: Control Weaknesses over and noncompliance with Enrollment Reporting RESPONSE: Southern University - Baton Rouge (SUBR) concurs with the above noted finding. Management concurs with this finding. Southern University and A&M College, especially the Office of Financial Aid, and the Office of the Registrar, are committed to ensuring full compliance with federal regulations and improving their reporting processes. Management fixed the file structure with the assistance of an external consultant. Management has also begun a comprehensive review of the current enrollment reporting procedures to identify and address gaps in compliance with federal regulations. New internal controls are being established to verify the accuracy and timeliness of enrollment reporting, including additional data validation checks before submission to NSLDS. The University has engaged an external consultant to assist with assessment and are exploring system upgrades to streamline and automate the submission processes to prevent recurring issues associated with manual operations outside of Banner 9. We acknowledge the auditor's recommendations to strengthen our policies, procedures, and practices for modifying enrollment statuses and tracking these changes promptly. Training sessions will be provided to all enrollment staff, including registrar, to reinforce compliance requirements and reporting deadlines for Federal Pell Grant and Federal Direct Student Loan recipients. Managers will be assigned to monitor and audit enrollment data accuracy and submission timeliness continuously. Regular internal audits will be conducted to ensure ongoing compliance with periodic reports submitted to senior management for review. Management anticipate all corrective actions and implementation to be completed over the next several months, with quarterly progress updates provided to relevant stakeholders. Management is committed to taking the necessary steps to strengthen enrollment reporting procedures and ensure compliance with federal regulations to support students and maintain SUBR's reputation for regulatory compliance. The Vice Chancellor of Enrollment Management Anthony Jackson and Associate Vice Chancellor of Accountability and Accreditation Scott Wicker be responsible for implementing and monitoring corrective actions. If you have any questions or require additional information, please contact Mrs. Desiree Honore Thomas, Associate Vice President at 225-771-3571.

View Audit 350759

Finding 541859 (2024-007)

Significant Deficiency 2024

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.308 § 200.309 § 200.344 § 200.403

Dear Mr. Waguespack, Please find below the University's management response to the audit finding titled “Noncompliance with Period of Performance Requirements." Management Response: The University concurs with the audit finding. Expense Posting Delay ($28,833): This salary charge reflects work pe...

Dear Mr. Waguespack, Please find below the University's management response to the audit finding titled “Noncompliance with Period of Performance Requirements." Management Response: The University concurs with the audit finding. Expense Posting Delay ($28,833): This salary charge reflects work performed within the approved award period. The delay occurred because the Personnel Action Form was received after the June payroll run, resulting in disbursements in July and August. Although the work was completed on time, the payroll posting did not align with the period of performance requirements. We are reviewing our processes to ensure all required documentation is received and processed promptly. Liquidation of Obligations ($34,957): The University failed to liquidate obligations totaling $34,957 within 120 days following the period of performance. This shortfall is due to staffing challenges in the Sponsored Programs Finance Administration and Compliance (SPFAC) Department. The University is actively exploring strategies to attract and retain qualified grant accountants to improve timely fund closeouts. Additional Mitigation Measures 1. Engaging External Consultants: o The University will engage an outside consultant to assess the university's research and administration structure, identifying opportunities to enhance processes and ensure compliance. o The University is retaining interim professional staffing to assist with invoicing and pre-audit review and to provide functional and technical expertise. 2. Deployment of an Electronic Research Administration System (eRA) o The University has begun identifying and implementing an electronic research administration system to transform grant management by offering a centralized platform that automates the entire lifecycle from proposal to closeout, minimizing manual errors while ensuring policy compliance and providing clear portfolio visibility through comprehensive reporting capabilities. The SPFAC Director will oversee the implementation of these corrective actions.

View Audit 350759 Questioned Costs: $1

Finding 541852 (2024-011)

Significant Deficiency 2024

State of Louisiana

LA

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Dear Mr. Waguespack, Please find enclosed the Louisiana Workforce Commission's response to the above-mentioned finding. On behalf of Secretary Susana Schowen, we thank your staff for their guidance and technical assistance throughout this process. If you have any questions or need additional inform...

Dear Mr. Waguespack, Please find enclosed the Louisiana Workforce Commission's response to the above-mentioned finding. On behalf of Secretary Susana Schowen, we thank your staff for their guidance and technical assistance throughout this process. If you have any questions or need additional information, please do not hesitate to give me a call at (225) 342-3474 or email at swilliams@lwc.la.gov. Noncompliance and Inadequate Controls Related to Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA) The Louisiana Workforce Commission concurs with the audit finding Noncompliance and Inadequate Controls Related to Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA). We have taken proactive steps to ensure that internal controls have been implemented to address issues of non-compliance. The Office of Workforce Development has revised policy OWD 1-9.1, Federal Funding Accountability and Transparency Act to align with Uniform Guidance 2 CFR 200.303 and 170, Appendix A (l)(a) requiring non-federal entities receiving federal award to establish and maintain internal controls, and requiring the reporting of subaward information in the FFATA Subaward Reporting System (FSRS) no later than the end of the month following the month in which obligation was made. The policy includes guidance and requirements on reporting timelines, process and procedure, internal reviews by appropriate management staff, and maintenance and storage (electronic file) of evidence of the review and approval of report information and submission. This information will be made available upon request. All relevant OWD staff have been provided training on how the FSRS operates, how data is entered in the system, how reports are generated, and all associated timelines of submission. The OWD Grants Manager and Compliance and Monitoring Administrator have been trained on the required review and approval process prior to report submission, including accurate and timely submission of all subawards. The Grants Manager is responsible for entering data into the FSRS no later than the end of the month following the month of obligation. A draft report will be submitted to the Compliance and Monitoring Administrator for review and approval. Once approved, the final report will be submitted in the FSRS. This process may be repeated each month as required based upon the issuance of each subaward. This revised process has been fully implemented effective July 3, 2024. OWD leadership will be provided monthly updates to include initial subawards, corrections, and modifications to ensure compliance is met and maintained.

View Audit 350759

Finding 541810 (2024-001)

Material Weakness 2024

City of Huntington Park

CA

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City will work with vendor to provide hard copies of all work done to assist in compliance. Planned Implementation Date: Implemented during Quarter 1 of Fiscal Year 2...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City will work with vendor to provide hard copies of all work done to assist in compliance. Planned Implementation Date: Implemented during Quarter 1 of Fiscal Year 2025 Responsible Person: Finance & Community Development Departments

View Audit 350727

Finding 541796 (2024-005)

Significant Deficiency 2024

Baylor College of Medicine

TX

Matching / Level of Effort / Earmarking Student Financial Aid Cash Management § 200.303

Finding 2024‐005 Student Financial Assistance Cluster ALN: 84.268 Finding: The College did not submit the required monthly reconciliation for the direct loan program Corrective Action Plan: To address the issue of not submitting the required monthly reconciliation for the Direct Loan Program, the...

Finding 2024‐005 Student Financial Assistance Cluster ALN: 84.268 Finding: The College did not submit the required monthly reconciliation for the direct loan program Corrective Action Plan: To address the issue of not submitting the required monthly reconciliation for the Direct Loan Program, the Financial Aid office has implemented a process to ensure Direct Loan reconciliation is completed monthly. An outlook calendar reminder entry will serve as a reminder to begin the reconciliation process on the 15th of each month. The Senior Financial Aid Counselor requests a YTD SAS report from COD, which contains loan data from the central processor, the report is delivered to our electronic mailbox within 24 hours. The Senior Financial Aid Counselor runs a second report from the SIS System to generate YTD loan disbursement information. The files are reformatted and compared by the Senior Financial Aid Counselor. Any discrepancies are reviewed and resolved in the appropriate system (COD or SIS), dependent on the discrepancy. The Senior Counselor notifies the Senior Manager of Financial Aid that the comparison and updates are complete. The Senior Manager of Financial Aid then reviews delta from the compared data and verifies that corrections are made in the correct system. The Senior Manager ensures that resolved amount is within the COD delta found on the summary page in COD and a screenshot is maintained in the reconciliation file. Senior Manager marks “Sr Manager Reviewed” column on the loan reconciliation spreadsheet with a date of review as evidence. The completed reconciliation is maintained in the Financial Aid Shared Directory. Person Responsible: Scott Moore, Senior Manager, Financial Aid, Baylor College of Medicine Expected Completion: April 2024

View Audit 350695

Finding 541794 (2024-004)

Material Weakness 2024

Baylor College of Medicine

TX

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

Finding 2024-004 Reporting ALN: 21.027 Finding: The College did not submit monthly reports for the CSLFRF or TCMHCC grants by the 15th of each month. Corrective Action Plan: BCM agrees that these reports were not submitted by the 15th deadline. Going forward, BCM will require the department to at...

Finding 2024-004 Reporting ALN: 21.027 Finding: The College did not submit monthly reports for the CSLFRF or TCMHCC grants by the 15th of each month. Corrective Action Plan: BCM agrees that these reports were not submitted by the 15th deadline. Going forward, BCM will require the department to attest that the programmatic reports were submitted when the monthly financial reports are submitted on the TCMHCC grant. Person Responsible: Chryll Batiste, Director, Research Administration, Baylor College of Medicine Expected Completion: April 2025

View Audit 350695

Finding 541119 (2024-003)

Material Weakness 2024

Baylor College of Medicine

TX

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

2024-003 Indirect Costs ALN: Research and Development Cluster (R&D), 21.027 Finding: The College did not retain documentation and evidence of review of the indirect cost amounts being charged to the R&D and CSLFRF programs. Management performed a monthly control that included reviewing a sample of...

2024-003 Indirect Costs ALN: Research and Development Cluster (R&D), 21.027 Finding: The College did not retain documentation and evidence of review of the indirect cost amounts being charged to the R&D and CSLFRF programs. Management performed a monthly control that included reviewing a sample of indirect costs charged to grants on a sample basis. The College had a new ERP implementation that went into effect on January 1, 2024. Management did not perform the monthly control subsequent to the ERP implementation for the last 6 months of year. Corrective Action Plan: With the implementation of the new ERP system, BCM went from an on-premises solution to a software-as-a-service solution. Since we no longer have access to modify the code that calculates the F&A expense on awards, management concluded that previous random testing control was no longer necessary. Management also believes that there are numerous compensating reporting controls that would alert us if the F&A calculations were not accurate. Notably, management’s compensating controls and the testing the audit firm conducted identified no instances where the F&A calculations were inaccurate. However, to satisfy this audit finding we will be resuming the manual control procedure used with the legacy system. Person Responsible: Chryll Batiste, Director, Research Administration, Baylor College of Medicine Expected Completion: April 2025

View Audit 350695

Finding 541110 (2024-003)

Significant Deficiency 2024

Bethany Lutheran College, Inc.

MN

Student Financial Aid Equipment & Real Property Management Matching / Level of Effort / Earmarking

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend that the Corporation review each element of GLBA to ensure compliance with all necessary requirements. Explanation of disagreement with audit finding: There is no...

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend that the Corporation review each element of GLBA to ensure compliance with all necessary requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College will update its Written Information Security Program to include a description of the use of a data inventory that includes how we identify and manage data, personnel, devices and facilities. Some of these items can be found in the other documents submitted but we will merge them into our WISP. Multi-factor authentication is in use for individuals accessing sensitive information but that also was not clearly identified in the WISP and will be added. To ensure GLBA compliance going forward, the College has contracted FRSecure to develop a risk assessment and roadmap which will do system scan for issues, an assessor will interview staff including IT, HR, Finance Leaders and others to learn more about the currentstate of overall security program. Compliance with GLBA will be part of their review. Finally,FRSecure will issue an assessment ‘Roadmap Plan’ for the department to review andpending results, implement as feasible.

View Audit 350688

Finding 541105 (2024-002)

Significant Deficiency 2024

Bethany Lutheran College, Inc.

MN

Student Financial Aid Reporting Significant Deficiency

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the Corporation review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanat...

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063 Recommendation: We recommend the Corporation review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: While this is classified as a repeat finding as it involves enrollment reporting, it is a different type of issue than prior year, which involved withdrawal date reporting. The College will implement a process to ensure that the beginning term date matches the enrollment record. The College will make sure that the campus enrollment date will not be affected by change of major date going forward and will make sure that correct dates are coming across and being correctly populated from the Admissions Department. Name of the contact person responsible for corrective action: Jeff Younge, Director of Financial Aid Planned completion date for corrective action plan: Fiscal Year 2025

View Audit 350688

Finding 541104 (2024-001)

Significant Deficiency 2024

Fairfield University

CT

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Corrective Action The corrective action that will be taken is that Pell Grant disbursements will be reported timely to COD. The following will support this effort: 1. Address Systematic Issues 2. Enhance Staff Training 3. Implement Regular Monitoring and Auditing Persons Responsible for Corre...

Corrective Action The corrective action that will be taken is that Pell Grant disbursements will be reported timely to COD. The following will support this effort: 1. Address Systematic Issues 2. Enhance Staff Training 3. Implement Regular Monitoring and Auditing Persons Responsible for Corrective Action The corrective action plan will be completed by Corry Unis, Vice President for Enrollment Management and Diana Draper, Executive Director of Financial Aid. Completion Date Initial corrective action was taken by Diana Draper, Financial Aid Director, in March 2024 when the student disbursements were reports to COD. Additional corrective actions included systematic controls, additional training, and greater internal monitoring and auditing have been put in place.

View Audit 350686

Finding 541097 (2024-006)

Material Weakness 2024

Manchester Community Schools

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

FINDING 2024-006 Finding Subject: COVID-19 Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Shelly Leifer Contact Phone Number and Email Address: 260.306.3359 shelly_leifer@mcs.k12.in.us Views of Responsible Officials: We concur with the finding Description ...

FINDING 2024-006 Finding Subject: COVID-19 Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Shelly Leifer Contact Phone Number and Email Address: 260.306.3359 shelly_leifer@mcs.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The comptroller will reach out to the IDOE regarding the dates required for submission. The comptroller, with the curriculum director, will populate the spreadsheet. The comptroller will get a signature from the assistant superintendent or superintendent before submittal. Anticipated Completion Date: March 31, 2025

View Audit 350682

Finding 541095 (2024-005)

Material Weakness 2024

Manchester Community Schools

IN

Matching / Level of Effort / Earmarking § 200.208 § 200.303

FINDING 2024-005 Finding Subject: COVID-19 Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Shelly Leifer Contact Phone Number and Email Address: 260.306.3359 shelly_leifer@mcs.k12.in.us Views of Responsible Officials: We concur with the finding Description...

FINDING 2024-005 Finding Subject: COVID-19 Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Shelly Leifer Contact Phone Number and Email Address: 260.306.3359 shelly_leifer@mcs.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The curriculum director and comptroller will make sure funds are entered correctly into the accounting software to ensure accurate tracking of expenditures. The comptroller will complete the financial report based on IDOE’s instructions. The curriculum director will review it for accuracy and initial. The assistant superintendent will review it for accuracy and initial. The comptroller will submit the jot form. Anticipated Completion Date: March 31, 2025

View Audit 350682

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