Corrective Action Plans

Finding 541976 (2024-003)

Significant Deficiency 2024

Honey Lake Valley Resource Conservation District

CA

Reporting § 200.502

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 approva...

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 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 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 541889 (2024-029)

Material Weakness 2024

State of Louisiana

LA

Special Tests & Provisions Reporting Internal Control / Segregation of Duties

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated December 4, 2024 regarding a reportable audit finding related to Noncompliance with Managed Care Provider Enrollment and Screening Requirement. LDH...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated December 4, 2024 regarding a reportable audit finding related to Noncompliance with Managed Care Provider Enrollment and Screening Requirement. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Noncompliance with Managed Care Provider Enrollment and Screening Requirement Recommendation: LDH should ensure all providers are screened and enrolled as required by federal regulations. LDH Response: LDH concurs with the finding that not all Managed Care Entity (MCE) providers were enrolled as of June 30, 2024. The Department and MCEs worked extensively with existing providers in 2021 and 2022 to encourage completion of enrollment. Providers who were newly credentialed with MCEs, since March 2022, had not been invited to enroll because it required a contract amendment with Gainwell Technologies and additional costs. Corrective Action: Gainwell Technologies contract amendment 26 was approved by CMS and the Office of State Procurement. The amendment requires the contractor to build a process to accommodate newly enrolled providers with one or more of the MCEs into the existing Louisiana Medicaid Provider Enrollment web-based portal. This process is known as re-baselining and will enroll providers on a regular and ongoing basis, bringing LDH to full compliance with federal regulations. Due to the volume of providers needing to be enrolled, two groups were created, and a staggered mailing schedule was developed as follows: Group 1: The first flight of invitation letters was mailed on October 25, 2024, and the final flight was mailed on November 8, 2024. Providers have 120 days to complete enrollment, with an estimated completion date of March 8, 2025. Group 2: The first flight of invitation letters is scheduled to be mailed on December 31, 2024, and the final flight on January 17, 2025. Group 2 has an estimated enrollment completion date of April 11, 2025. After completion of the two groups, LDH will be in full compliance, and a new bi-monthly cycle will be utilized to invite incoming providers to enroll thereafter. LDH is also seeking a longer-term solution through the National Association of State Procurement Officials (NASPO) Value Point that will modernize the provider management system and achieve the CMS preference of modularity. A Provider Management Module vendor was selected in 2023, but a protest was filed which halted any implementation activities. Due to the lengthy delay that resulted from the protest, LDH requested to cancel the procurement and start over. LDH has restarted the procurement process and is leveraging the NASPO approach due to a change in law that no longer allows for a protest for a NASPO procurement. We anticipate to have a new vendor selected by January of 2025. You may contact Kimberly Sullivan, Medicaid Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@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 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 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 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 541849 (2024-009)

Significant Deficiency 2024

State of Louisiana

LA

Subrecipient Monitoring Reporting § 200.303

Dear Mr. Waguespack: The Division of Administration is submitting the following as a response to the audit finding titled “Noncompliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act”. The DOA agrees with the LLA that the subawards tested were not reported...

Dear Mr. Waguespack: The Division of Administration is submitting the following as a response to the audit finding titled “Noncompliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act”. The DOA agrees with the LLA that the subawards tested were not reported in the Federal Funding and Accountability and Transparency Act Subaward Reporting System (FSRS) within the required time frame. The Office of Community Development – Local Government Assistance and the Office of Community Development – Disaster Recovery have revised written procedures to increase the frequency of reporting and reviews, which should reduce or prevent future errors. The contact person responsible for the corrective action is Traci Watts, OCD Director or Ginger Moses, OCD Chief Operating Officer. If you have questions or require additional information, please feel free to contact me.

View Audit 350759

Finding 541847 (2024-005)

Material Weakness 2024

State of Louisiana

LA

Allowable Costs / Cost Principles Reporting Procurement, Suspension & Debarment § 200.303 § 200.430

Dear Mr. Waguespack, Thank you for the opportunity to respond to your office’s findings related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff. LSUHSC-S concurs with the recommendations to address th...

Dear Mr. Waguespack, Thank you for the opportunity to respond to your office’s findings related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff. LSUHSC-S concurs with the recommendations to address the findings and provides the following response and corrective action plan. Recommendation: Management should ensure they have adequate controls over time and effort certifications, purchases, and reimbursement requests. In addition, management should ensure adequate segregation of duties covering approvals of all transaction types. Response and Corrective Action Plan: Effective FY25, LSUHSC-S has implemented an electronic Time & Effort certification system through PeopleSoft in conjunction with New Orleans. Training in the new system was provided by the New Orleans IT Department to all departmental Business Managers. Technical support questions are addressed by OSP Post Award and New Orleans IT Department. LSUHSC-S Administrative Directive 4.4 will be revised to include the new electronic process. The Office of Research Administration will hold Post-Award Monitoring meetings with all principal investigators and designated departmental staff on a quarterly basis. These meetings will begin in March 2025. During these meetings, Grant Managers from OSP Post Award will review grant ledgers to ensure that all grant accounts are reconciled monthly. Departmental Business Managers will sign off on the completed monthly reconciliations. Personnel expenditures will be included in this monthly review. Discrepancies will be reviewed with the PI and business manager for accuracy and possible corrective action plan. Prior to submission, OSP Pre-Award will provide the RPPR to the PI and Business Manager for review and certification, to ensure time and effort allocations match the current budget and PER report. OSP Pre-Award will aid Business Managers as needed. A new PER electronic system was implemented and the AD for Cost Transfer is being revised and approved. The revised AD will require greater detail in the justification for changes in source funding for salaries. Justification must meet the requirements in the revised AD. A new Standard Administrative Procedure will be implemented in March 2025 that requires all salary changes on grant accounts to be made no later than 90-days after the effective date. All requests that are greater than 90 days will be evaluated through a rigorous review process and may or may not be approved. LSUHSC-S Research Administration will ensure accurate information is available and provided to auditors upon request in a timely manner. LSUHSC-S will explore the implementation of additional PS module vendor transaction utility, such as adding more approvers, to ensure adequate segregation of duties for approval. The removal of the ability for self-approval of requisitions within the PeopleSoft requisition workflow will prevent a requestor and an approver from being the same person. A monthly report will be auto-generated and emailed (ad-hoc ability as well) to the Director of Purchasing and the Executive Director of Financial Operations. The report will list detailed requisition information to include the requestor names and approver names of requisitions created for that period for review to ensure the approval process is properly working. Name of Contact(s) Responsible for Action Plan Ramey Benfield, Chief Financial Officer, Vice Chancellor for Research Administration Jen Katzman, Vice Chancellor, Administration and Budget (with Departmental Business Managers) Tracy Calvert, Associate Director, Office for Sponsored Programs Post Award William Haacker, Assistant Director, Office for Sponsored Programs Post Award Steven McAlister, Associate Director of General Accounting Anticipated Completion Date: Continuous

View Audit 350759

Finding 541821 (2024-005)

Significant Deficiency 2024

South Carolina State Housing Finance and Development Authority

SC

Questioned Costs HUD Housing Programs Special Tests & Provisions

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Compliance Requirement: Special Tests and Provisions – Rolling Forward Equity Balances Recommendation: We recommend the Authority review the equity roll forward of programs to identify and correct errors in the correct reporting p...

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Compliance Requirement: Special Tests and Provisions – Rolling Forward Equity Balances Recommendation: We recommend the Authority review the equity roll forward of programs to identify and correct errors in the correct reporting period. Views of responsible officials: There is no disagreement with the audit finding. Action planned/taken in response to finding: After the end of the Audit period, HCV and Finance staff worked together to correct equity roll forward concerns. All reporting to HUD has been corrected and a process is in place to reconcile the accounts monthly so that adjustments can be timely made. Name(s) of the contact person(s) responsible for corrective action: Elaine Bouse, Accounting Manager Tyeshia Brunson, HCVP Lead Admin Corrie Temples, Regulatory Analyst (support) Planned completion date for corrective action plan: Currently implemented and ongoing.

View Audit 350735 Questioned Costs: $1

Finding 541811 (2024-002)

Significant Deficiency 2024

City of Huntington Park

CA

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

Management Response and Corrective Action Plan The City concurs with the recommendation. Corrective Action Plan: City is onboarding qualified individuals to ensure reports are submitted in a timely manner and retained by the City. Planned Implementation Date: Implemented during Quarter 1 of Fiscal Y...

Management Response and Corrective Action Plan The City concurs with the recommendation. Corrective Action Plan: City is onboarding qualified individuals to ensure reports are submitted in a timely manner and retained by the City. Planned Implementation Date: Implemented during Quarter 1 of Fiscal Year 2025 Responsible Person: Director of Finance

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 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 541103 (2024-003)

None 2024

Overton County, Tennessee

TN

Questioned Costs Reporting

Deficiencies were also in the 2022-2023 school year in regard to actions of former employees improperly receiving compensation for time not worked during the afterschool program and inaccurately reporting attendance for the afterschool program. Immedately upon finding the deficiencies, all deficienc...

Deficiencies were also in the 2022-2023 school year in regard to actions of former employees improperly receiving compensation for time not worked during the afterschool program and inaccurately reporting attendance for the afterschool program. Immedately upon finding the deficiencies, all deficiencies were corrected during FY 23.

View Audit 350683 Questioned Costs: $1

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 541077 (2024-003)

Material Weakness 2024

Ninnekah School District I-51

OK

Reporting Internal Control / Segregation of Duties Material Weakness

The accounting staff and management responsible for coding within the District will consistently oversee and conduct monthly edit checks in the accounting software to assess all expenses and confirm their coding accuracy. These monthly checks will help identify any coding mistakes in the Oklahoma Co...

The accounting staff and management responsible for coding within the District will consistently oversee and conduct monthly edit checks in the accounting software to assess all expenses and confirm their coding accuracy. These monthly checks will help identify any coding mistakes in the Oklahoma Cost Accounting System, ensuring that expenses are thoroughly reviewed and corrected as necessary. Any inquiries or issues regarding coding will be addressed in collaboration with the Oklahoma State Department of Education and/or school auditors to confirm the appropriate coding options. Monthly spreadsheets have been developed and will be submitted to the Superintendent for evaluation following the reconciliation of claims related to Federal expenditures. The Expenditures of Federal Awards will match the numbers submitted to the Oklahoma Cost Accounting System. Additionally, encumbrances will be examined at the end of the year and will be closed if found to be inaccurate. All actions will be corrected by June 30, 2025.

View Audit 350679

Finding 541071 (2024-001)

Significant Deficiency 2024

Mental Health Association of Maryland, Inc.

MD

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

Views of Responsible Officials: We acknowledge the audit finding regarding the documentation of personnel time. To address this issue, we have implemented the following corrective actions and will continue to enhance our process: 1. Enhanced Training: We are providing comprehensive training to all r...

Views of Responsible Officials: We acknowledge the audit finding regarding the documentation of personnel time. To address this issue, we have implemented the following corrective actions and will continue to enhance our process: 1. Enhanced Training: We are providing comprehensive training to all relevant staff on the importance of accurate timesheet entry/review and the proper procedures for documenting and allocating personnel expenses. 2. Improved Internal Controls: We have strengthened our internal control procedures to ensure that timesheets are completed accurately, reviewed thoroughly, and retained properly. Allocations are additionally entered into the payroll system for further accuracy. These are reviewed and approved then entered into the accounting system. This is then reconciled to the payroll system for further accuracy. 3. Regular Audits: We are conducting regular internal audits of timesheet and payroll records to ensure ongoing compliance with documentation standards and to identify any areas needing improvement. 4. Accessible Records: We have established a system for the retention of allocation documentation in a readily accessible format to facilitate future audits and ensure transparency. 5. Addressing Turnover: We recognize that high turnover rates within the finance and program departments have contributed to these issues. To mitigate this, we will continue to focus on improving staff retention through enhanced support, training, and development opportunities, ensuring continuity and consistency in our documentation processes.

View Audit 350674

Finding 541068 (2024-101)

Significant Deficiency 2024

City of South Tucson

AZ

Reporting § 200.327

Condition: During the audit, the auditors noted three of seven monthly Federal Financial Reports were filed late. Specifically, the July 2023, August 2023 and May 2024 reports were filed later than 30 days as required under the County’s contract. Recommendation: The auditors recommended that the C...

Condition: During the audit, the auditors noted three of seven monthly Federal Financial Reports were filed late. Specifically, the July 2023, August 2023 and May 2024 reports were filed later than 30 days as required under the County’s contract. Recommendation: The auditors recommended that the County improve internal controls over grant reporting that includes a process that identifies reporting requirements, including reporting deadlines, and monitors timely grant reporting. Corrective Action Planned: The County Community Services department will improve the timeliness and accuracy of grant reporting by implementing the following measures. An automated task list will be implemented to clearly identify billing report due dates, responsible staff, report recipients, and the required reporting frequency. This system will enhance accountability and help ensure deadlines are consistently met. A separate automated task will be established to ensure Community Services receives accurate and timely billing reports from grantors. This proactive approach will help identify and resolve potential delays before they impact reporting compliance. If unforeseen circumstances impact reporting timelines Community Services will utilize internal departmental data to prepare preliminary billing reports to prevent delays and reconcile to final reporting when available. Additionally, Community Services will proactively communicate with grantors in the event of anticipated delays to maintain transparency and compliance. The County Finance department had already partially addressed this at the beginning of fiscal year 2025 with enhanced data gathering of grant reporting requirements and deadlines for each grant. This data is gathered prior to grant acceptance. The County Finance department will improve its process by providing frequent reminders at a standard frequency to all department directors and those who are directly responsible for grant reporting to follow the grantor reporting requirements. Additionally, these periodic communications will request that department directors confirm the accuracy of department grant contacts and provide updated contact information as needed. Contact Name: Christina Register, Assistant Director Community Services Anticipated Completion Date: June 30, 2025

View Audit 350672

Finding 541064 (2024-001)

Significant Deficiency 2024

Tasc of Southeast Oihio

OH

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

TASC of Southeast Ohio has implemented procedures and developed a schedule to ensure that the audited financial statements will be submitted, along with the data collection form, upon the release of the June 30, 2024 audit.

View Audit 350671

Finding 541038 (2024-002)

Significant Deficiency 2024

PA Chapter American Academy of Pediatrics

PA

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.430

Immunization Cooperative Agreements – Assistance Listing No. 93.268 During our testing, we noted the Chapter charges benefits to the programs based on an estimated allocation calculated based on the percentage of salaries as determined in the contract budget. However, we noted the Chapter does not ...

Immunization Cooperative Agreements – Assistance Listing No. 93.268 During our testing, we noted the Chapter charges benefits to the programs based on an estimated allocation calculated based on the percentage of salaries as determined in the contract budget. However, we noted the Chapter does not have internal controls in place to provide a review of the actual fringe benefits incurred. Recommendation: We recommend Pennsylvania Chapter, American Academy of Pediatrics establish a process for periodic after-the-fact reviews of interim charges made to federal awards based on budget estimates. Based on the review, management should make any necessary adjustments to the interim charges based on the results of the periodic reviews. This would ensure that the final amount charged to the federal award is accurate, allowable, and properly allocated. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Chapter will implement a process for the review of interim charges made to federal awards and make any necessary adjustments that ensure the final amount charged to the federal award is accurate, allowable and properly allocated. Name(s) of the contact person(s) responsible for corrective action: Annette Myarick, Executive Director Planned completion date for corrective action plan: The planned corrective action will be completed by June 2025.

View Audit 350641

Finding 541037 (2024-001)

Material Weakness 2024

Wild Rose School District

WI

Cash Management Reporting

The District acknowledges the finding and will continue to review new standards as part of the fiscal audit process.

View Audit 350640

Corrective Action Plans

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