Corrective Action Plans

Finding 544096 (2024-002)

Significant Deficiency 2024

New Reach, Inc.

CT

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding No. 2024-002: Compliance Reporting Description of Finding: The Organization submitted periodic reports that did not reconcile to the accounting records and were not submitted by the due date. Statement of Concurrence or Nonconcurrence: The organization agrees with this finding. Corrective Ac...

Finding No. 2024-002: Compliance Reporting Description of Finding: The Organization submitted periodic reports that did not reconcile to the accounting records and were not submitted by the due date. Statement of Concurrence or Nonconcurrence: The organization agrees with this finding. Corrective Action: In August 2024 the Organization engaged the services of an outside consultant who is a practicing CPA with extensive experience auditing not-for profit organizations. Policies and related procedures have been implemented to ensure the books and records are closed on a monthly basis and all reports are reviewed for agreement with the accounting records and approved prior to being filed. Name of Contact Person: Kellyann Day Chief Executive Officer, (203) 492-4866, kday@newreach.org Projected Completion Date: The project is anticipated to be completed during fiscal year 2025.

View Audit 350907

Finding 544091 (2024-007)

Significant Deficiency 2024

Jersey City Public Schools

NJ

Reporting

With respect to the American Rescue Plan (ARP)- ESSER Program: o The District's budget report related to the American Rescue Plan - ESSER program be reviewed to ensure that appropriations and resulting balances accurately reflect remaining program funds available. o The...

With respect to the American Rescue Plan (ARP)- ESSER Program: o The District's budget report related to the American Rescue Plan - ESSER program be reviewed to ensure that appropriations and resulting balances accurately reflect remaining program funds available. o The Board resolution approving hourly rates for employees funded by the American Rescue Plan - ESSER program be amended to reflect revised contractual rates. In addition, timesheets for such employees be signed for approval by the appropriate supervisory personnel.

View Audit 350893

Finding 544090 (2024-006)

Significant Deficiency 2024

Jersey City Public Schools

NJ

Student Financial Aid Reporting

The District's budget report related to the ESEA Title IV program be reviewed to ensure that appropriations and resulting balances accurately reflect remaining program funds available.

View Audit 350893

Finding 544084 (2024-002)

Significant Deficiency 2024

Wide Ruins Community School

AZ

Reporting

Finding Number: 2024‐002 Program Names/Assistance Listing Titles: Indian School Equalization, Indian Education Facilities, Operation, and Maintenance Assistance Listing Numbers: 15.042, 15.047 Contact Person: Aurelia Tapaha, Business Manager Anticipated Completion Date: April 2025 Planned Corrective...

Finding Number: 2024‐002 Program Names/Assistance Listing Titles: Indian School Equalization, Indian Education Facilities, Operation, and Maintenance Assistance Listing Numbers: 15.042, 15.047 Contact Person: Aurelia Tapaha, Business Manager Anticipated Completion Date: April 2025 Planned Corrective Action: The School will start submitting SF‐425 Quarterly report before the last day of the month. Attend training provided by Bureau of Indian Education to learn of compliance with federal regulations and guidelines.

View Audit 350888

Finding 544082 (2024-001)

Significant Deficiency 2024

Bridgewater College

VA

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

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

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

View Audit 350883

Finding 544075 (2024-001)

Material Weakness 2024

Williams Unified School District No. 2

AZ

Subrecipient Monitoring Material Weakness Reporting

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: April 7,2025 Planned Corrective Action: WUSD2 has designed and implemented an effective internal ...

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: April 7,2025 Planned Corrective Action: WUSD2 has designed and implemented an effective internal control procedure to ensure that the federal reporting is tracked and completed in a timely manner. The Business Manager and Federal Programs Director will meet monthly to review grant funding and reporting. This will include any deadlines for submissions of grants and reporting.

View Audit 350877

Finding 544070 (2024-006)

Significant Deficiency 2024

Mandaree Public School District No 36

ND

Reporting

Contact Person: Business Manager Planned Corrective Action: The Business Manager currently maintains a file which includes documentation in support of all amounts submitted on federal quarterly SF-425 reports. Planned Completion Date: Throughout the fiscal year ending June 30, 2025 and ongoin...

Contact Person: Business Manager Planned Corrective Action: The Business Manager currently maintains a file which includes documentation in support of all amounts submitted on federal quarterly SF-425 reports. Planned Completion Date: Throughout the fiscal year ending June 30, 2025 and ongoing

View Audit 350871

Finding 544063 (2024-001)

Material Weakness 2024

Brandywine Community Resource Council Dba Claymont Community Center

DE

Reporting Internal Control / Segregation of Duties

Management acknowledges the recommendation and has begun considering controls consistent with the recommendation. Appropriate year-end closing procedures will be written to document required reconciliations and related internal controls over completeness and accuracy.

View Audit 350868

Finding 544054 (2024-001)

Significant Deficiency 2024

Intecare, INC

IN

Reporting Significant Deficiency Internal Control / Segregation of Duties

SIGNIFICANT DEFICIENCY 2024-01 Financial Reporting Recommendation: The organization should ensure: • Internal controls are in place and performed throughout the year to enable an efficient year end closing process. • Documentation of the performance of internal reviews over reconciliations and jour...

SIGNIFICANT DEFICIENCY 2024-01 Financial Reporting Recommendation: The organization should ensure: • Internal controls are in place and performed throughout the year to enable an efficient year end closing process. • Documentation of the performance of internal reviews over reconciliations and journal entries is retained and is readily available. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An external application is now being used to track reviews of journal entries and reconciliations to make up for this being a missing feature in the accounting system. Name(s) of the contact person(s) responsible for corrective action: Noah Masson Planned completion date for corrective action plan: 8/1/2024

View Audit 350867

Finding 542032 (2024-002)

Significant Deficiency 2024

The Pennsylvania State University

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Finding Number: 2024-002, Effort Certification Condition: One of the internal controls that the University has designed related to ensuring that personnel expenses charged to federal grants were accurate is an effort certification that is completed at least annually. This control was not operating ...

Finding Number: 2024-002, Effort Certification Condition: One of the internal controls that the University has designed related to ensuring that personnel expenses charged to federal grants were accurate is an effort certification that is completed at least annually. This control was not operating effectively during the year ended June 30, 2024, as certain effort certifications were not completed timely. Planned Corrective Action: Penn State raised awareness of the late effort certification issue at various committee and council meetings during Fall 2024 and enforced compliance with our existing policy. These meetings involve research leadership at all colleges, such as Associate Deans for Research, College Research Administration Officers, and College Financial Officers. Penn State followed its policy on overdue effort certifications, and we have implemented additional internal controls in the process. The University’s Office of the Senior Vice President for Research has restructured oversight of effort certification, along with many other post award financial matters, to a newly created office, Post Award Contractual Compliance (PACC). This office includes the existing Research Accounting Office (which was part of the Office of Budget and Finance prior to July 1, 2024), and Penn State has hired an Assistant Vice President to oversee this team. A new suboffice, led by a new director, within PACC is the Financial Analysis and Compliance Office (FACO), which is responsible for central oversight and training over the effort certification process. This office has recently created a new dashboard to monitor the completion of effort certifications and works closely with business units within Penn State to ensure timely completion via sending out reminders, holding meetings, and providing training on the process. Contact person responsible for corrective action: John Hanold, Associate Vice President for Research; Director, Office of Research Administrative Services Anticipated Completion Date: June 30, 2025

View Audit 350858

Finding 542030 (2024-002)

Significant Deficiency 2024

University of Pikeville

KY

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

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

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

View Audit 350857

Finding 542004 (2024-002)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles Cash Management Reporting

2024-002 C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommen...

2024-002 C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should reassess the design of its controls to ensure submissions to BHSB are made timely within the required 15-day period and that documentation is retained that evidences the review and approval of expenditures submitted to BHSB for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendations. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. Additionally, management will develop a federal grant policy that includes the requirements for compliance and internal controls for federal grants. The policy will acknowledge that for controls to be designed and operate effectively, there must always be a segregation of duties between the preparer of the control vs. reviewer and that clear documentation must be retained to evidence the execution of the controls. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 350833

Finding 541997 (2024-001)

Significant Deficiency 2024

Grand Street Settlement Senior

NY

HUD Housing Programs Period of Performance Reporting

2024-001: Financial Reporting Management agrees with the finding and has taken immediate steps to address the issue and ensure timely submissions. Grand Street Settlement and BTQ Financial, Inc. will jointly oversee and ensure the timely submission of all progress reports. All agreements will be re...

2024-001: Financial Reporting Management agrees with the finding and has taken immediate steps to address the issue and ensure timely submissions. Grand Street Settlement and BTQ Financial, Inc. will jointly oversee and ensure the timely submission of all progress reports. All agreements will be reviewed in detail to fully understand compliance and reporting requirements, ensuring that all conditions are met, and submissions are made on time. A detailed timeline will be established for each reporting period, with regular check-ins to ensure that progress reports are completed and submitted on schedule. All deadlines will be closely monitored to prevent any future delays. Status of Finding: Management is expected to resolve the finding during fiscal year 2025 and will continue to work on resolving the finding. Managements Response: Management agrees with the finding. The issue will be corrected and resolved by the Grand Street Settlement Director of Administration, Program Director, and BTQ Financial during the fiscal year 2025.

View Audit 350812

Finding 541996 (2024-004)

Material Weakness 2024

University City District

PA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.327 § 200.328

Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organi...

Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organization which will include the monthly financial statements, general ledger detail, a listing of all journal entries made, significant accounts reconciliations, aged payables and receivables, and any significant adjustments in the previous period. Report will also include an update to the Schedule of Federal Awards and other significant grant reporting done in conjunction with the development team. President will review and approve the packet monthly. Expected Completion Date: 3/31/2025

View Audit 350805

Finding 541990 (2024-004)

Significant Deficiency 2024

College Unbound

RI

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

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

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

View Audit 350797

Finding 541985 (2024-001)

Significant Deficiency 2024

Southwestern Area Workforce Developement Board

NM

Subrecipient Monitoring Reporting

Corrective Action Plan: Please describe below how the situation in the finding will be corrected. What action(s) will be done (refer to finding recommendation and agency response) The SAWDB will strengthen the process in which it monitors compliance with the requirements of Section 129(a)(4)(A), W...

Corrective Action Plan: Please describe below how the situation in the finding will be corrected. What action(s) will be done (refer to finding recommendation and agency response) The SAWDB will strengthen the process in which it monitors compliance with the requirements of Section 129(a)(4)(A), WIOA, 128 Stat. 1506 and develop a strategy to exceed the minimum 75 percent of funds to out-of-school youth. Quarterly review and monitoring will take place during the Monitoring Committees meeting. The fiscal administrator will provide the report. A direct review of percentages of expenditures will be analyzed by fiscal administrator, Program Manager, Program Monitor, and WIOA Administrator prior to reporting to the monitoring committee. Who will act (name and title): Skylar Arnold, Fiscal Admin Glory Juarez, WIOA Admin Jaymi Simms WIOA Program Manager When will action(s) be completed (effective dates, timelines, etc.): SAWDB will ensure that Earmarking Compliance is reviewed and maintained at or over the minimum percentage allowed. This is start immediately and reported to Monitoring Committee Quarterly. These enhanced procedures will be performed to resolve this finding before June 30, 2025.

View Audit 350791

Finding 541979 (2024-001)

Significant Deficiency 2024

Town of Easton (the Easton Utilities Commission)

MD

Subrecipient Monitoring Reporting Significant Deficiency § 200.305

State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Allowable Activities and Costs - Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the Commission establish policies and procedures over internal controls to ensure review and approval of SEFA...

State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Allowable Activities and Costs - Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the Commission establish policies and procedures over internal controls to ensure review and approval of SEFA preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will implement a SEFA preparation policy. Name of the contact person responsible for corrective action: Tracie Thomas Planned completion date for corrective action plan: May 31, 2025

View Audit 350782

Finding 541977 (2024-002)

Material Weakness 2024

Marana Health Center, INC

AZ

Procurement, Suspension & Debarment Cash Management Reporting

The Controller will review the detailed information related ot the drawdown to ensure the amount charged to the specific grant is allowable, reasonable and properly supported prior to when the drawdown is requested.

View Audit 350780

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

Corrective Action Plans

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