Corrective Action Plans

Finding 2022-006The Corporation management agreed with the finding. As of August 16, 2023, the Corporation has implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to prop...

Finding 2022-006The Corporation management agreed with the finding. As of August 16, 2023, the Corporation has implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to properly maintain evidence of controls. The below wording was added to the SEFA Preparation Memo, which is used to prepare the SEFA each year.a. Grants listed on the prior year are reviewed to determine if the grant is still active or if the grant has closed out.i. For grants that have closed the ending dates of the grant are verified, and current year activity is reviewed to ensure that all activity for that grant has been properly accounted for.Responsible Personnel include Harley McCoige, Controller and Cortney Couture, Director of Accounting.

View Audit 312518

Finding 442908 (2022-002)

Material Weakness 2022

Beacon Health System, Inc.

IN

Subrecipient Monitoring Questioned Costs Matching / Level of Effort / Earmarking

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 e...

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.

View Audit 312518 Questioned Costs: $1

Finding 442907 (2022-004)

Material Weakness 2022

Beacon Health System, Inc.

IN

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting

Finding 2022-004 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Special Test and ProvisionsThe Corporation management agreed with the finding. Effective September 1, 2022, The Corporation has implemented the following changes, which we believe would add...

Finding 2022-004 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Special Test and ProvisionsThe Corporation management agreed with the finding. Effective September 1, 2022, The Corporation has implemented the following changes, which we believe would address future internal control considerations.The below procedures were added to the grant checklist which is required on all grants applied for by the Corporation entities. Responsible parties are required to document all procedures and sign off on these procedures. The requirements formalize reporting and data management procedures, which include proper management approval and retention of these records. The grant checklist is additionally approved by the grant applicant and Vice President or Executive Director overseeing the grant.Determine required data requests in order to support this grant:? All data requests should list required data fields and constraints and must be reviewed and approved by management.? Detail sample review of the results must be performed to validate the accuracy and completeness of data and that report results meet the grant requirements.? Report access should be restricted to approved users or report results must be validated to approved constraints.Documentation of these procedures must be retained with management sign off and readily available upon request.Grants in excess of $187,500 require review by Finance or Internal Audit representative to verify that appropriate procedures are in place for documentation of controls on reporting and data management.Responsible Personnel beyond the specific Vice President or Executive director of the grant include Harley McCoige, Controller, Cortney Couture, Director of Accounting, and Samantha Pratt, Director of Internal audit.

View Audit 312518

Finding 442906 (2022-001)

None 2022

Beacon Health System, Inc.

IN

Questioned Costs Subrecipient Monitoring Eligibility

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 s...

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.

View Audit 312518

Finding 442905 (2022-001)

Significant Deficiency 2022

Community Legal Aid Society, Inc.

DE

Questioned Costs

GSA_MIGRATION

View Audit 312517 Questioned Costs: $1

Finding 442903 (2022-002)

Significant Deficiency 2022

Latino Resource Institute of Illinois

IL

Questioned Costs Internal Control / Segregation of Duties

MANAGEMENT?S CORRECTIVE ACTION PLANLATINO RESOURCE INSTITUTE OF ILLINOISFOR THE YEAR ENDED JUNE 30, 2022Finding 2022-002 Adherence and Application of Fiscal and Accounting Policiesand ProceduresFederal Agency: U.S. Department of Health and Human ServicesPass-through Entities: Chicago Department of P...

MANAGEMENT?S CORRECTIVE ACTION PLANLATINO RESOURCE INSTITUTE OF ILLINOISFOR THE YEAR ENDED JUNE 30, 2022Finding 2022-002 Adherence and Application of Fiscal and Accounting Policiesand ProceduresFederal Agency: U.S. Department of Health and Human ServicesPass-through Entities: Chicago Department of Public HealthThe Chicago Cook Workforce PartnershipProgram Name: Epidemiology and Laboratory Capacity of Infectious Diseases(ELC)Assistance Listing #: 93.323Questioned Costs: NoneWe agree with the auditor?s comments, and actions stated in the recommendation. In fiscal year 2023, the Employee Handbook and the Fiscal and Accounting Policies and Procedures were updated. To strengthen internal control, the Organization will expand its Fiscal and Accounting Policies and Procedures to include evidence of review and approval of the Executive Director. In addition, the Executive Director is researching for best practices and talking with other organizations about accounting so that the Organization can adhere to its policies and procedures.Contact Person: Hector Obregon-Luna, Executive DirectorAnticipated Completion Date: June 30, 2023

View Audit 312514

Finding 442902 (2022-002)

None 2022

Washington Parish School Board

LA

Questioned Costs Reporting

2022-002 Compliance with Reporting Requirements 1. Responsible departments will keep a checklist of required reports to be submitted along with due dates of such reports. Goal Date: 3/31/2023 Person Responsible for Corrective Action: Department Heads 2. Report submission dates will be documented. An...

2022-002 Compliance with Reporting Requirements 1. Responsible departments will keep a checklist of required reports to be submitted along with due dates of such reports. Goal Date: 3/31/2023 Person Responsible for Corrective Action: Department Heads 2. Report submission dates will be documented. Any exceptions will be noted. Goal Date: 3/31/2023 Person Responsible: Department Heads

View Audit 312512

Finding 442879 (2022-003)

Material Weakness 2022

Copa Health, Inc.

AZ

Questioned Costs Internal Control / Segregation of Duties § 200.303

Finding 2022-003Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionCFDA #93.498Finding Summary: The Organization?s special reports submitted to the Department of Health and HumanServices were not re...

Finding 2022-003Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionCFDA #93.498Finding Summary: The Organization?s special reports submitted to the Department of Health and HumanServices were not reviewed and approved by a separate individual outside of the preparer.Responsible Individuals: CFO Martin Quintana, and Controller Gladys LopezCorrective Action Plan: We reviewed the internal controls and provided better separation of duties in the process.Steps were added to the process that entail a review of the preparers? work by a second person before they aresubmitted to the Controller and/or the Chief Financial Officer for approval. Will also establish a process forensuring full review of financial statements.Anticipated Completion Date: By 11/30/2023

View Audit 312508

Finding 442878 (2022-002)

Material Weakness 2022

Copa Health, Inc.

AZ

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionCFDA #93.498Finding Summary: The Organization?s final expenditure listing identified as eligible and claimed under theProvider Reli...

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionCFDA #93.498Finding Summary: The Organization?s final expenditure listing identified as eligible and claimed under theProvider Relief Fund program lacked documentation of its review by a separate individual outside of thepreparer. The support for two out of 60 expenditures tested differed in amounts from the amount on thetracking spreadsheet. Three of the 60 invoices did not include evidence of approval for payment.Responsible Individuals: CFO Martin Quintana, and Controller Gladys LopezCorrective Action Plan: We reviewed the internal controls and provided better separation of duties in the process.Steps were added to the process that entail a review of the preparers? work by a second person before they aresubmitted to the Controller and/or the Chief Financial Officer for approval. Will also establish a process forensuring full review of financial statements.Anticipated Completion Date: By 11/30/2023

View Audit 312508

Finding 442867 (2022-005)

Significant Deficiency 2022

United Way of Greater Cleveland

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are app...

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are applied to the correct period for the correct amount after the Accounting Coordinator inputs the data to ensure that Federal funds are reimbursed accurately and in the appropriate period

View Audit 312506 Questioned Costs: $1

Finding 442866 (2022-004)

Significant Deficiency 2022

United Way of Greater Cleveland

OH

Allowable Costs / Cost Principles Questioned Costs Cash Management

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are app...

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are applied to the correct period for the correct amount after the Accounting Coordinator inputs the data to ensure that Federal funds are reimbursed accurately and in the appropriate period.

View Audit 312506 Questioned Costs: $1

Finding 442865 (2022-003)

Significant Deficiency 2022

United Way of Greater Cleveland

OH

Cash Management Reporting Questioned Costs

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 ...

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.

View Audit 312506 Questioned Costs: $1

Finding 442859 (2022-002)

Significant Deficiency 2022

The Cleveland Play House

OH

Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.302 § 200.403

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...

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

View Audit 312500 Questioned Costs: $1

Finding 442852 (2022-004)

Material Weakness 2022

South Montgomery Community School Corporation

IN

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

FINDING 2022-004Contact Person Responsible for Corrective Action: Kristin CharlesContact Phone Number: 765-866-0203Views of the Responsible Official: The School Corporation is in agreement with the Finding.Description of Corrective Action Plan: This should not be an issue moving forward as now writ...

FINDING 2022-004Contact Person Responsible for Corrective Action: Kristin CharlesContact Phone Number: 765-866-0203Views of the Responsible Official: The School Corporation is in agreement with the Finding.Description of Corrective Action Plan: This should not be an issue moving forward as now write our grant to be used for our Co-Op Bill and do not pay salaries directly. In the future if we plan to pay with Federal Funding, we will require time and effort logs.Anticipated Completion Date: 4/1/2023

View Audit 312499 Questioned Costs: $1

Finding 442840 (2022-006)

Significant Deficiency 2022

South Montgomery Community School Corporation

IN

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

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

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

View Audit 312499

Finding 433484 (2022-003)

Significant Deficiency 2022

Nevada System of Higher Education

NV

Internal Control / Segregation of Duties Questioned Costs Student Financial Aid § 200.303

STUDENT FINANCIAL ASSISTANCE CLUSTER FINDINGSFINDING 2022-003 - Internal Control over Compliance (Repeat Finding 2021-003, 2020-001, 2019-002, 2018-003, 2017-002, 2015-002, 2014-008)ResponsesNSHE Overall response/context ?NSHE increased its dialogue amongst the three instances of the student informa...

STUDENT FINANCIAL ASSISTANCE CLUSTER FINDINGSFINDING 2022-003 - Internal Control over Compliance (Repeat Finding 2021-003, 2020-001, 2019-002, 2018-003, 2017-002, 2015-002, 2014-008)ResponsesNSHE Overall response/context ?NSHE increased its dialogue amongst the three instances of the student information system throughout fiscalyear 2022. The results of this robust dialogue led to additional controls to reduce related IT risks, enhancedmonitoring of activities, and targeted periodic reviews, highlighted in each instance?s response below. Theseenhanced techniques operating throughout the entire fiscal year ahead, should provide a stronger overall controlenvironment and lower associated risks.UNR ?? Detailed corrective action taken, including what will be done to avoid the identified issues inthe future, and when these measures will be in place;UNR has implemented controls to address the risk associated with the PeopleSoft Administrators(PSA?s) access to the production and development environments. The controls include:1. The University will remove the PSA role for the three individuals that are identified as not havingthe appropriate segregation of duties. The PSA role is still required of the University and will onlybe granted on a temporary basis when necessary and this access will be, documented, monitored,and deactivated upon completion of the required tasks.a) Approvals ? A PSA role is granted for task specific business needs and when the individualssecurity level does not permit the action to be performed. When justified, the PSA role isgranted by a security administrator.b) Documented ? When the PSA role is granted a notification is triggered to the Associate VicePresident, Planning, Budget and Analysis, the Registrar and the Director of AccountingOperations as to the role assignment and the person assigned.c) Monitored ? The activities performed are documented and monitored in a TeamDynamixticket.d) Deactivated ? The PSA system access is deactivated upon completion of the required activity.The deactivation is documented in the TeamDynamix ticketing system.2. The University will implement a quarterly User Access Review that identifies the incidences ofwhen the PSA role is granted and when the PSA login occurs and compares this to Team Dynamixto establish the activity. The activity can be compared to the system for validity. This will beperformed by the Registrar. 3. The University will continue to explore and research Change Control Systems as options tomonitor activities of the PSA?s.? How compliance and performance will be measured and documented for future audit,management and performance review.The PSA role will not be established for continuous periods of time. When the PSA role is temporarilygranted it is documented and tracked in Team Dynamix. This provides an audit trail of role access,timeframes of logins, and activities.? Who will be responsible and may be held accountable in the future if repeat or similarobservations are noted.The Associate Vice President, Planning, Budget and Analysis will monitor the compliance with thecorrective action plans and will implement new processes as needed to meet the needs of mitigatingthis risk and the system updates and changes.UNLV ?UNLV agrees with this finding.? Detailed corrective action taken, including what will be done to avoid the identified issues inthe future, and when these measures will be in place;UNLV understands the importance of adequate segregation of duties within the PeopleSoftenvironments and applications. The PeopleSoft Administrator (PSA) position that is the subject ofthe finding is responsible for the installation, configuration, upgrades, and troubleshooting of all theapplication environments. The PeopleSoft Administrators are not programmers/developers, andtheir access to the production environments is periodically required to perform the needed activitiesrequired to provide timely support of the application within the scope of their job duties.UNLV has implemented the following controls to mitigate the risks associated with the elevatedaccess required for the administrators to perform their required support activities.a. UNLV will remove the PeopleSoft Administrator role from all PSAs in productionenvironments.b. The PeopleSoft Administrator role will be assigned temporarily when elevated actions arerequired. The assignment will have the following requirements:i. Be limited in duration.ii. Document a justification detailing the need and actions to be performed.iii. Generate notification to the Director of Enterprise Applications.iv. Automatically be removed.v. It is reviewed as part of normal audit activities. c. UNLV will increase their reviews of access, activities, and assigned privileges to monthly forthe PeopleSoft Administrators.d. UNLV will continue researching and implementing other control methods to address thesegregation of duties while providing appropriate service and support.? How compliance and performance will be measured and documented for future audit,management and performance review.The PeopleSoft Administrator role will no longer be a persistent assignment to the PSA position.UNLV will perform monthly reviews of the access and activities to determine if the PeopleSoftAdministrators' current levels require further refinement. Additionally, UNLV will continue toresearch other control methods that will address the segregation of duties while providingappropriate service and support.? Who will be responsible and may be held accountable in the future if repeat or similarobservations are noted.The Director of Enterprise Applications will be responsible for reviewing the access needs of thePeopleSoft Administrators. The Director will complete the reviews and is also accountable if repeat orsimilar observations are noted. The Chief Information Security Officer will verify the reviews are permonthly audit practices.SCS ?? Detailed corrective action taken, including what will be done to avoid the identified issues inthe future, and when these measures will be in place;PeopleSoft Administrator (PSA) access to the Production and Development environments arereviewed on an ongoing basis. Due to the need to develop and perform program changes for all fiveshared-instance Institutions on a frequent basis it was determined that PSA access cannot be reducedany further. However, to address the segregation of duties risk the following compensating controlsare in place:(a) STAT for PeopleSoft ? Code control and internal modification tracking provides visibility over PSAactivities that are processed via this tool. These object changes are reviewed and approved by theDirector of Information and Application Services.(b) JIRA - Change control management and project tracking software. Change requests and projectsrelated to the PeopleSoft shared instance are tracked and approved. This would include user accessmodifications and system updates for example.(c) Security e-mail alerts ? The SCS security team are alerted via automated e-mails when user access(to include PSA roles) is changed.(d) User Access Reviews ? On an annual basis a user access review is performed incorporatingSCS/SA privileged users and all shared instance security coordinators SCS will implement the following additional control from FY22/23 going forward:(e) Splunk reporting and monitoring ? Reporting and trigger events developed incorporating PSAactivity ?anomalies?. For example, PSA after-hour logins reviewed and matched to plannedupdates/activities.(f) Periodic management reviews ? A formal review incorporating, and documenting PSA andassociated exception activities will take place. Where appropriate this will include approvals anddocumented rationale.SCS will continue to explore additional solutions to minimize the segregation of duties risk, especiallyas it relates to the monitoring of PSA activities.? How compliance and performance will be measured and documented for future audit,management and performance review.The periodic management review where appropriate will include documentation and approvals tosupport PSA activities that do not meet established criteria. This review will also document anyfollow-ups required as it relates to similar controls. For example, security e-mail alerts.? Who will be responsible and may be held accountable in the future if repeat or similarobservations are noted.SCS Director of Information and Application Services, SCS Security Group.

View Audit 312392

Finding 433372 (2022-004)

Significant Deficiency 2022

Nevada System of Higher Education

NV

Questioned Costs Special Tests & Provisions Student Financial Aid

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

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

View Audit 312392

Finding 433358 (2022-028)

Material Weakness 2022

State of Louisiana

LA

Questioned Costs Procurement, Suspension & Debarment Eligibility

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 13, 2023, regarding a reportable audit finding related to Inadequate Controls over Eligibility Determinations. LDH appreciates the opportuni...

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 13, 2023, regarding a reportable audit finding related to Inadequate Controls over Eligibility Determinations. LDH appreciates the opportunity to provide this response to your office's findings.Finding: Inadequate Internal Controls over Eligibility DeterminationsRecommendation: LDH should ensure its employees follow procedures relating to eligibility determinations and redeterminations in the Medicaid and CHIP programs to ensure the case records support the eligibility decisions.LDH Response: LDH does not concur with this finding.The audit period occurred during the COVID-19 Public Health Emergency (PHE). The federal Centers for Medicare & Medicaid Services (CMS) which has oversight of the Medicaid and CHIP programs has issued a number of guidance documents which set forth and at times changed actions and steps States should be taking to comply with the FFRCA continuous eligibility provision as well as preparing for the end of the PHE. Program decisions that affected normal policy and procedures were made based on guidance at that particular time while also being cautious to not jeopardize enhanced federal matching funds under the FFRCA by inappropriately terminating an individual's coverage during the PHE.Audit staff indicated three instances of Medicaid and two instances of CHIP beneficiaries not having renewals performed and documented per the Medicaid eligibility manual.LDH notified audit staff it was still operating under a March 25, 2020 approved waiver from CMS on certain flexibilities in meeting the timeliness of Medicaid renewals in accordance with 42 CFR ? 435.912(e)(2). CMS' approval stated, in part:Louisiana has indicated that the agency expects that it will be unable to meet timeliness requirements for processing applications, completing renewals and acting on changes in circumstances through the duration of the emergency. We understand that to prevent coverage from being terminated inappropriately if Louisiana is unable to complete renewals timely, the agency may need to set a future renewal date in the eligibility system. Federal regulation at 42 CFR 435.912(f) requires the agency to document the reason for delay in each applicant's and beneficiary's case record.LDH, as did other states, used this flexibility to suspend renewals during the PHE. LDH continued to try and process renewals through an ex parte basis and only suspended those that would require requesting information from beneficiaries. While there was no particular documentation in the "case note" section of the Louisiana Medicaid Eligibility Determination System (LaMEDS), LDH provided audit staff with LaMEDS log tables which documented system jobs called "data fixes" that were completed which set certain renewals to a future date per the approved flexibility. LDH continues to firmly believe the "case record" contemplated in CFR 435.912(f) includes all aspects of data repositories or system actions in the case, along with text fields in the case notes and the documents in the LDH document management system. In accordance with 42 CFR 433.112(b) and 45 CFR 164.312(b), LaMEDS logs system activity and enables the State to examine and document system actions.Audit staff cited one instance of coverage that was not discontinued on a beneficiary invalidly enrolled prior to the start of the PHE. LDH staff did not timely act on a task to terminate coverage for this beneficiary prior to the beginning of the PHE in March 2020. Under the continuous eligibility provision of the FFCRA of 2020, a state could not terminate individuals from Medicaid if such individuals were enrolled in the program as of the date of the beginning of the emergency period, unless the individual voluntarily terminates eligibility or is no longer a resident of the state. No exceptions were noted for delays in taking negative action, therefore, when LDH staff tried to process the termination in April 2020, system implemented restrictions for the continuous enrollment provision prevented it.In November 2020, CMS issued an Interim Final Rule (CMS-9912-IFC) which provided additional information concerning the continuous enrollment period and allowable terminations and transitions during the PHE. The Interim Final Rule clarified that states may terminate coverage prior to the end of the PHE for beneficiaries not validly enrolled. Defined at 42 CFR 433.400, a beneficiary is not validly enrolled if the agency determines that the determination of eligibility was incorrect at the most recent determination, redetermination, or renewal of eligibility because of agency error or fraud. CMS guidance for the Interim Final Rule issued as an update to the Frequently Asked Questions (FAQ) for the continuous enrollment section of the FFRCA indicated that "as of November 2, 2020, references to "coverage" in this FAQ should be read as "enrollment" and the continuous enrollment condition should be applied only to "validly enrolled" beneficiaries as defined at? 433.400(a)." The Interim Final Rule nor the FAQ guidance that followed provided any instruction to review or take action on cases that were prevented from terminating prior to its release. LDH applied the clarification of "validly enrolled" on decisions going forward therefore the beneficiary's coverage remained open.LDH did agree with Audit staff in the one instance where the beneficiary was not terminated for moving out of state. Established procedures were not followed to confirm the out of state address and terminate coverage appropriately.With the explanation provided to audit staff during their review and repeated here, LDH does not agree there was a lack of internal controls over eligibility determinations that warrant a finding.You may contact Tara A. Leblanc, Medicaid Executive Director at (225) 219-7810 or via e-mail at Tara.LeBlanc@la.gov or Rhett Decoteau, Medicaid Section Chief at (225) 342- 9044 or via email at Rhett.Decoteau@la.gov with any questions about this matter.

View Audit 312391

Finding 433356 (2022-026)

Significant Deficiency 2022

State of Louisiana

LA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Dear Mr. Waguespack,The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 10, 2023, regarding a reportable audit finding related to Inadequate Controls over Drug Rebate Collections. LDH appreciates the opportunity to prov...

Dear Mr. Waguespack,The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 10, 2023, regarding a reportable audit finding related to Inadequate Controls over Drug Rebate Collections. LDH appreciates the opportunity to provide this response to your office's findings.Finding: Inadequate Controls over Drug Rebate Collections.Recommendation: LDH should ensure that agency personnel are adequately monitoring contract provisions for the drug rebate program and follow-up procedures are performed for all drug rebate invoices that have not been fully collected or disputed in a timely manner.LDH Response: LDH does not concur with this finding and recommendation.LLA issued a finding April 14, 2022 regarding partially paid invoices. LDH responded to the finding on April 22, 2022 regarding 2021 procedures. LLA immediately audited SFY 2022 after the SFY 2021 finding. As a result, there was not enough time to build out the CAP before the end of the SFY22, June 30, 2022.Based on the finding and response in late April, it was determined Magellan Medicaid Administration would email labelers at the 45-day late letter mark. The 45-day mark for the May 2022 invoicing cycle was on July 11, 2022. The 45-day mark before that would have been April 11, 2022, before the finding.In the brief interim before the end of SFY 2022, measures were taken by LDH and Magellan (end of April, May & June) to begin setting up the mechanisms to address collections on partial payment accounts. First quarter partial payment accounts were addressed with the 45-day Dunning Notices, July 11, 2022 and are currently being monitored. Magellan has been manually sending Dunning Notices to all manufacturers that made partial payments. This procedural change is to help increase collection rates.Corrective Action Plan and progress addressing the findings are listed below:1) Magellan regularly provides LDH with an Aged Receivables and Disputes Dashboard. This visual spreadsheet shows open balance data for federal and supplemental rebate programs, along with original invoice information, collection rates, and open disputes over the past 4 quarters (starting the week of April 24, 2022). LDH holds weekly meetings with Magellan to review the data and recommend changes. The dashboard is updated quarterly.2) Magellan has built a team to work on rebate related manufacturer operations focused on accounts receivables and disputes.? Magellan has built a manufacturer-focused team.? Magellan has addressed partial payments by sending Dunning Notices to manufacturers.3) Magellan will begin emailing all labelers with outstanding balances. An email template is being created and will be provided to LDH during the week of April 24, 2022 for approval.? LDH approved an-email template. However, after additional consideration it was determined this was not needed.? Upon further review and discussion by LDH and Magellan it was determined that Magellan would not email all Labelers with outstanding balances over 150 days. The "late" letters Magellan sends to manufacturers at 45-day, 75-day, and 90-day marks were sufficient. The letters serve as a 60-day letter, per ODR statute. The 45-day and the 75- day letters can suffice as the reminder letter to be sent to the debtor to pay the debt within 60 days before transfer to ODR.4) Magellan will change its automated Dunning Notices process to include labelers that made partial payments. This procedural change will continue to help increase the collection rate.? Magellan began emailing all labelers with partial payments. Magellan sent the first email on 7/11/22 to all labelers that made partial payments to the 1Q22 invoices? The automated Dunning Notices process will be changed to include labelers that made partial payments as part of the RxLink implementation, which is planned to go live in February 2023.? In the interim, the updated process for late letters that includes partial payments has been:1. Dunning #IA sent through an automated process to labelers that made no payments- 45 days after original postmark2. Dunning #1B manually emailed to labelers that made partial payments and for which the total outstanding balance is greater than $25 - 45 days after original postmark.3. Dunning #2A sent through an automated process to labelers that made no payments - 75 days after original postmark4. Dunning #2B manually emailed to labelers that made partial payments and for which the total outstanding balance is greater than $25 - 75 days after original postmark5. Next Quarterly Invoice plus Prior Period Statement- includes total balance due for prior periods6. Dunning #3A sent through an automated process to labelers that made no payments - 90 days after original postmark7. Dunning #3B manually emailed to labelers that made partial payments and for which the total outstanding balance is greater than $25 - 90 days after original postmark8. Dunning #4 sent through an automated process to labelers that made no payments - 210 days after original postmarkEffective 02/2023, all dunning letters will be sent through an automated process to labelers that made no payments and to labelers that made partial payments. This will be part of RxLink Implementation.In regards to additional procedures for collection of partial payments, Magellan previously invoiced quarterly and included invoices for past quarters not fully paid in the subsequent quarter. In addition, after 210 days of not receiving payment in full, Magellan's Rebate team reviewed outstanding balances and reached out to manufacturers.You may contact Tara A. LeBlanc at (225) 219-7810 or via e-mail at Tara.LeBlanc@LA.GOV or Germaine Becks-Moody, Medicaid Program Manager at (225) 342-9479 or via email at germaine.becks-moody@la.gov with any questions about this matter.

View Audit 312391

Finding 433354 (2022-024)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 27, 2023, regarding a reportable audit finding related to Inadequate Controls Over and Noncompliance with National Correct Coding Initiative...

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 27, 2023, regarding a reportable audit finding related to Inadequate Controls Over and Noncompliance with National Correct Coding Initiative Requirements. LDH appreciates the opportunity to provide this response to your office?s findings.Finding: Inadequate Controls Over and Noncompliance with National Correct Coding Initiative RequirementsRecommendation: Management should ensure all required NCCI edits are properly applied to FFS claims.LDH Response: LDH partially concurs with this finding.LDH disagrees with the premise that a data pull compared with NCCI quarterly files represents an accurate and final adjudication of claims in a claims processing system. LDH disagrees that such a data pull could be used as the basis of a determination of inappropriate adjudication.The data pull does not consider the final adjudication of claims. Our review identified examples outside of the processing dates utilized by LLA where the NCCI edits applied and claims denied correctly in subsequent processing dates. A single data pull by the LLA may not dependably reflect the accurate final outcome of the applied edits.Fee-for-service (FFS) NCCI editing occurs within the integrated ClaimsXten Portfolio (CXT P) (formerly Change Healthcare) `ClaimCheck? product. System constraints of both the fiscal intermediary and ClaimCheck preclude applying Medically Unlikely Edits (MUE) to outpatient hospital and durable medical equipment (DME) claims.The LLA has been previously informed that Medicaid FFS is working with the fiscal intermediary (FI) and CXT P to implement and integrate the newest version of the clinical editing product, `ClaimsXten? which houses all of the Medicaid NCCI methodologies. This product replaces ClaimCheck and will not have the same constraints in applying NCCI edits. LDH is currently in the process of converting to `ClaimsXten?. The estimated completion date is March 24, 2023.The LLA is also aware that FFS Medicaid applies the Medicaid NCCI `procedure to procedure? (PTP) edits for practitioner, outpatient hospital (OPH), and durable medical equipment (DME) as well as the medically unlikely edits for practitioners. DME and OPH MUE are not currently applied due to previously mentioned system constraints. CMS is aware of the methodologies applied to Louisiana Medicaid FFS claims.LDH concurs that not all of the Medicaid NCCI edit methodologies are in place due to the limitations of the fiscal intermediary and the current integrated editing product.Corrective Action Plan:As ongoing corrective action, LDH is working with both the FI and CXT P to integrate and implement the updated clinical editing product `ClaimsXten? that will allow full compliance with all of the NCCI edit methodologies.LDH will continue to perform biweekly reviews that include examples of FFS NCCI edits to assure correct functionality. Once `ClaimsXten? is implemented, all methodologies will be able to be monitored. The estimated completion date is March 24, 2023.You may contact Tara A. Leblanc, Medicaid Director at (225) 219-7810 or via e-mail at Tara.LeBlanc@la.gov or Brandon Bueche, Medicaid Section Chief at (225) 384-0460 or via email at Brandon.Bueche@la.gov with any questions about this matter.

View Audit 312391 Questioned Costs: $1

Finding 433352 (2022-022)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Eligibility Internal Control / Segregation of Duties

Dear Mr. Waguespack:The Louisiana Department of Education (LDOE) appreciates the opportunity to submit an official response to the audit finding entitled: Weakness in Controls over Child Care Development Fund Grants. The LDOE concurs in part with the finding. The LDOE was aware of the risks of distr...

Dear Mr. Waguespack:The Louisiana Department of Education (LDOE) appreciates the opportunity to submit an official response to the audit finding entitled: Weakness in Controls over Child Care Development Fund Grants. The LDOE concurs in part with the finding. The LDOE was aware of the risks of distributing this large amount of funds while using systems not made for these purposes, and therefore, put in place specific additional controls to enhance the LDOE?s existing recoupment and fraud processes which are designed to control and capture these situations.Issue 1: LDOE overpaid six child care providers who received ARPA Child Care Stabilization funds by a total of $59,063. The LDOE is conducting final reviews and assessments for the ARPA Round 1 and 2 grants and firmly believes these overpayments would have also been captured during this audit process. The amount of funds classified as overpayments for this issue represents 0.01% of funds distributed. The LDOE has already recouped funds from five of the six providers associated with these overpayments through existing processes. The LDOE will clarify and/or amend existing procedures to include enhanced evaluation of grant distribution calculations for all future work. In addition, the LDOE will also return to previously processed issues and evaluate all grant distribution calculations.Issue 2: During LDOE?s review of payments to child care providers who received grant payments funded with CRRSA and ARPA funds, LDOE identified overpayments to 11 child care providers totaling $887,212. LDOE has represented that they recover. The LDOE has recouped 96% of the funds from overpayment and continues the work necessary to recoup the remaining amount. In response to the payment errors experienced with prior grants, the LDOE has begun executing test runs in the system to allow us to review the award amount compared to the payment amount prior to the actual payment. Additionally, LDOE is working to identify additional controls to capture possible errors early in the process.The Child Care and Development Fund (CCDF) is the primary federal funding source for child care subsidies to help eligible low-income working families access child care and improve child care for all children. The CARES Act, Coronavirus Response and Relief Supplemental Appropriations Act, and the ARP Act appropriated additional supplemental CCDF Discretionary funds. This funding was to provide Lead Agencies with additional funds to prevent, prepare for, and respond to the Coronavirus Disease 2019 (COVID-19), and expand flexibility to provide child care assistance to families and children. The Administration for Children and Families, Office of Child Care strongly encouraged Lead Agencies to quickly get funds to child care providers in order to stabilize the industry and ensure child care for families.In order to provide support to the child care providers of Louisiana as soon as possible, the LDOE opened the application period for the first stabilization grant in a very short time period. Since the first grant, the LDOE has received and processed over 10,500 grant applications and distributed approximately $497 million dollars to child care providers to meet the intent of the law.Thank you for the opportunity to respond to this issue. Kim Nesmith, Director of Early Child Care and Education Administrative Affairs and Child Care and Development Fund Administrator, will be the contact person responsible for corrective action that will be completed by June 30, 2023. The LDOE is committed to implementing the necessary procedures to improve these processes.

View Audit 312391 Questioned Costs: $1

Finding 433336 (2022-034)

Material Weakness 2022

State of Louisiana

LA

Questioned Costs Special Tests & Provisions Reporting § 200.308

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 sh...

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.

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