Corrective Action Plans

Finding 391258 (2023-002)

Significant Deficiency 2023

FL

Subrecipient Monitoring Eligibility Significant Deficiency § 200.303

Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the feder...

Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The State of Florida’s Department of Financial Services’ State Projects Compliance Supplement Part Five: Internal Controls Section D. Eligibility states that recipients should develop Control Objectives to provide reasonable assurance that only eligible individuals and organizations receive assistance under state projects, that subawards are made only to eligible subrecipients, and that amounts provided to or on behalf of eligibles were calculated in accordance with project requirements. During our testing of participant eligibility, we noted that supervisory personnel did not properly review and approve their eligibility documentation prior to the participant entering the program for ten of 80 participants selected for eligibility testing. Corrective Actions Taken or Planned: Corrective measures were taken with the Program Leadership responsible for the eligibility documentation noted above. The following corrective actions are in the process of being implemented: • CHS’s Program Leadership and their teams will conduct a review of respective intake forms completed after July 1, 2023 to ensure that all were properly reviewed and approved. Any unapproved intake forms identified will be verified and retroactively approved by the designated supervisor. • In cases where there are instances of unapproved intake forms, the Program Leadership will collaborate with the respective Talent Business Partner to follow up with formal corrective action. Such corrective action will include: o A thorough review of the CHS policies and practices relative to the management and approval of intake forms. o Mandatory refresher education and training with all staff to ensure they understand the steps required to document review and approval of the intake process, as well as the importance of maintaining evidence that the process was adequately performed. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Brungardt, Chief Program and Clinical Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.

View Audit 301878

Finding 391248 (2023-003)

Significant Deficiency 2023

Saint Elizabeth University

NJ

Student Financial Aid Questioned Costs Matching / Level of Effort / Earmarking

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates...

Common Origination and Disbursement (COD) Reporting Planned Corrective Action: The University’s Financial Aid Office will update the anticipated disbursement date to reflect the actual disbursement for 2022-23. We will review the current award year to ensure that the anticipated disbursement dates reflect the actual disbursement date. Person Responsible for Corrective Action Plan: Nicholas Capodice, Director of Financial Aid Anticipated Date of Completion: April 30, 2024

View Audit 301872

Finding 391243 (2023-002)

Significant Deficiency 2023

Saint Elizabeth University

NJ

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University’s IT Department will work to update procedures and controls to ensure any federal regulations of the FTC Safeguards Rule (16 CFR § 314.4(b)(1) - 16 CFR § 314.4(i)) that were found to be in partial compliance are reme...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University’s IT Department will work to update procedures and controls to ensure any federal regulations of the FTC Safeguards Rule (16 CFR § 314.4(b)(1) - 16 CFR § 314.4(i)) that were found to be in partial compliance are remediated and brought into compliance. Some of these have already been remediated. We will work with other departments who administer third party vendor accounts to enforce MFA where there are gaps. A penetration test and the standing up of a tool to continuously monitor our network internally and those of third party vendors are already in startup phases Our information security program and risk assessment will be updated to reflect any recommendations offered by our auditors to fill any existing gaps in the 2023 audit. Person Responsible for Corrective Action Plan: Ron Loneker, Jr., Director, IT Special Projects Anticipated Date of Completion: May 31, 2024

View Audit 301872

Finding 391240 (2023-008)

Significant Deficiency 2023

City and County of Honolulu

HI

Subrecipient Monitoring § 200.332

Finding No. 2023-008: Subrecipient Monitoring (Significant Deficiency - Internal Control Over Compliance) Federal Award: 21.027 - COVID‐19 – Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Audit Recommendation: We recommend the City be more diligent in following its policies and proce...

Finding No. 2023-008: Subrecipient Monitoring (Significant Deficiency - Internal Control Over Compliance) Federal Award: 21.027 - COVID‐19 – Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for on‐site monitoring of its subrecipients. We also recommend the City implement control procedures to review a subrecipient’s most recent single audit report to determine if any management decisions on findings or monitoring is necessary. Administration’s Comments: The City will follow policies and procedures for on-site monitoring of its subrecipients and also implement control procedures to review a subrecipient’s most recent single audit report to determine if management decisions on findings or monitoring is necessary. OER will perform a verification to ensure that the subrecipient takes timely and appropriate action on deficiencies detected through their Single Audit. Anticipated Completion Date: July 31, 2024 Contact Person(s): Denise Obrero, Mayor’s Office, Planner VII

View Audit 301866

Finding 391239 (2023-007)

Significant Deficiency 2023

City and County of Honolulu

HI

Subrecipient Monitoring § 200.332

Finding No. 2023-007: Subrecipient Monitoring (Significant Deficiency - Internal Control Over Compliance) Federal Award: 21.023 - COVID‐19 – Emergency Rental Assistance Program (ERA) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for on‐site...

Finding No. 2023-007: Subrecipient Monitoring (Significant Deficiency - Internal Control Over Compliance) Federal Award: 21.023 - COVID‐19 – Emergency Rental Assistance Program (ERA) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for on‐site monitoring of its subrecipients. We also recommend the City implement control procedures to review a subrecipient’s most recent single audit report to determine if any management decisions on findings or monitoring is necessary. Administration’s Comments: The City will follow policies and procedures for on-site monitoring of its subrecipients and also implement control procedures to review a subrecipient’s most recent single audit report to determine if management decisions on findings or monitoring is necessary. OER will perform a verification to ensure that the subrecipient takes timely and appropriate action on deficiencies detected through their Single Audit. Anticipated Completion Date: July 31, 2024 Contact Person(s): Denise Obrero, Mayor’s Office, Planner VII

View Audit 301866

Finding 391233 (2023-004)

Material Weakness 2023

City and County of Honolulu

HI

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Finding No. 2023-004: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that subawards are uploaded to the FSRS system timely. Administration’...

Finding No. 2023-004: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that subawards are uploaded to the FSRS system timely. Administration’s Comments: The City will establish and follow policies and procedures to ensure that subawards are uploaded to the FSRS system timely. City will establish roles to improve execution of the reporting process. Anticipated Completion Date: June 30, 2024 Contact Person(s): Timothy Ho, Department of Community Services, Planner VII Holly Kawano, Department of Budget and Fiscal Services, Federal Grants Coordinator

View Audit 301866

Finding 391227 (2023-003)

Material Weakness 2023

San Andreas Sanitary District

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The District is actively working to develop written policies that will guide future procurement and selection of firms that participate in these federally-funded projects, including debarment and confli...

Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The District is actively working to develop written policies that will guide future procurement and selection of firms that participate in these federally-funded projects, including debarment and conflict of interest procedures. We plan to implement new policies by end of F& 23/24. Implementation Date: June 2024 Name of Responsible Person: Hugh Logan, General Manager

View Audit 301852

Finding 391198 (2023-002)

None 2023

Boys and Girls Clubs of Puerto Rico INC

PR

Subrecipient Monitoring Equipment & Real Property Management

Finding No. 2023-002 Management Response: Management agrees with the finding. The Organization has spent $20,268.79 in equipment that falls under the capitalization requirements of the program. The amount that has not been capitalized is $9,409.93, consisting of computer equipment. Corrective Action...

Finding No. 2023-002 Management Response: Management agrees with the finding. The Organization has spent $20,268.79 in equipment that falls under the capitalization requirements of the program. The amount that has not been capitalized is $9,409.93, consisting of computer equipment. Corrective Action Plan:  A capitalization procedure for CDGB-DR will be added to our Finance Policy and Procedure Manual.  Perform the adjustments in our fixed assets subsidiary Contact Person: Antonio Rosario Manuel Joglar Nerma Albertorio Team: Accounting Manager and program leaders. Anticipated Completion Date: June 30, 2024

View Audit 301810

Finding 391170 (2023-003)

Material Weakness 2023

Mercy Health

MO

Subrecipient Monitoring Allowable Costs / Cost Principles Equipment & Real Property Management § 200.303 § 200.333 § 200.403

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansa...

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Views of Responsible Officials and Planned Corrective Actions: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will implement testing of our inventory system (Lawson) to ensure calculations are accurate. All review and approvals of capital equipment will be maintained in Strata. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24

View Audit 301777 Questioned Costs: $1

Finding 391165 (2023-002)

None 2023

School District of Cambridge

WI

Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding #2023-002 – Elementary and Secondary School Emergency Relief Fund (ESSER) III Plan Condition: The District did not make its ESSER III Local Educational Agency (LEA) Plan Report readily and publicly available. Effect: By not making the plan available to the public, the District is effectivel...

Finding #2023-002 – Elementary and Secondary School Emergency Relief Fund (ESSER) III Plan Condition: The District did not make its ESSER III Local Educational Agency (LEA) Plan Report readily and publicly available. Effect: By not making the plan available to the public, the District is effectively not compliant with the Federal requirements for this program. Cause: The District was not aware of this requirement. Criteria: The OMB Compliance Supplement mandates a LEA to submit and make publicly available a plan for the safe return to in-person instruction and continuity of services, and the planned use of the ESSER III funding. Recommendation: The auditors recommend that the plan be made available on the District’s website. Response: We (the District) will upload the plan to the District’s website in order to make it publicly available. Cambridge School District’s Corrective Action Plan: The ESSER plans were posted on the district website until summer of 2023 when the website design was updated and information was migrated to new pages or eliminated if it was no longer relevant. As the ESSER LEA plan was associated with our COVID response plan and COVID related protocols were eliminated, the plan was removed. We were unaware that the plan needed to remain posted through the grant period. When we learned that the requirement to post the plan remains a requirement we promptly posted our WI DPI approved plan from DPI under the heading District Annual Notices. Contact Person: Margaret M. Banker, District Administrator/Business Manager Anticipated Completion Date: 9/01/2024

View Audit 301774

Finding 391146 (2023-004)

Material Weakness 2023

Ohio Institute of Allied Health, Inc.

IL

Questioned Costs Student Financial Aid Subrecipient Monitoring

FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and...

FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned We have revised the process of student stipends ofdisbursements. Each student whose account receives a disbursement whom results in a credit balance, will be given stipend prior to any draw down. We shall also make process and procedures with new third-party servicer to ensure stipend is sent prior to drawdown. Signed Betsy Bremke, Administrative Campus Director Date: _3/29/2024__

View Audit 301753 Questioned Costs: $1

Finding 391132 (2023-001)

Significant Deficiency 2023

City of Concord

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding Reference Number: SA2023-001 - Suspension and Debarment Documentation for Contracts and Subcontracts Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Federal Aw...

Finding Reference Number: SA2023-001 - Suspension and Debarment Documentation for Contracts and Subcontracts Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Federal Award Identification Number: SLFRP0424 • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Purchasing Manager • Corrective Action Plan: The purchasing division consists of (2) staff members. The division had turn over in both purchasing positions during fiscal year 2022/23. During this time, the documentation of disbarment checks by purchasing staff was not consistent. To strengthen this process, the City put multiple checks in place to ensure that City staff is aware of this requirement and is meeting this requirement: 1. Every Request for Proposal request that vendors certify that they are not on the exclusion list as part of the bidding or solicitation process. 2. When preparing a Request for a Purchase Order, departments have a checklist of "Required Documentation" to support the Requisition. A section has been added to check if the purchase will be funded by federal funds and, if yes, the department is to provide a screen shot of the disbarment check from sam.gov. 3. The REQUISITION/PO tracking sheet used by the Purchasing Account Clerk includes a column to mark that the disbarment check has been completed. 4. The instructions in the Purchasing Acct Clerk desk manual include instructions on how to complete a disbarment check as part of the "Creating a PO" script. • Anticipated Completion Date: June 30, 2024

View Audit 301716

Finding 391130 (2023-002)

Significant Deficiency 2023

City of Concord

CA

Subrecipient Monitoring Reporting

Finding Reference Number: SA2023-002 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV ...

Finding Reference Number: SA2023-002 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0009 COVID-19 – B-20-MW-06-0009 • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Leng Powers • Corrective Action Plan: In April 2023, City staff received training on the FFATA website and reporting requirements. After review of the website, the website's requirements, and the FFATA reporting requirements, City staff assigned reporting roles to individuals in Housing and Finance to report within 30 days of executing agreements of $30,000 with sub-recipients. During Fiscal Year 2022/23, the City entered into contract with (3) sub-recipients for awards over $30,000. These contracts were officially executed in December2022/January 2023. The City has been working to obtain the UEI and other miscellaneous reporting information from the sub-recipients in order to complete the required FFATA report for FY2022-23. Going forward, the City will require the FFATA information to be included in the sub-awardee prior to executing the grant award. • Anticipated Completion Date: June 30, 2024

View Audit 301716

Finding 391128 (2023-005)

Material Weakness 2023

Sioux Falls School District 49-5

SD

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

Identifying Number: 2023-005: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: The following instances were identified during testing of enrollment reporting: 7 instances in which a student’s status change was certified outside the 60-day re...

Identifying Number: 2023-005: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: The following instances were identified during testing of enrollment reporting: 7 instances in which a student’s status change was certified outside the 60-day reporting requirement, 7 instances in which a student’s status change was not reported within 60 days to the National Student Loan Data System (NSLDS) nor included in reporting to the National Student Clearinghouse (NSC), and 2 instances in which a student’s program start date reported in NSLDS did not agree with student records. Corrective Action Taken or Planned: The STC Financial Aid Office and Registrar will work to develop a process to review errors in the three systems that are involved in enrollment status reporting and identify any solutions. A common folder for submittal rosters will be shared between the offices so that they may also be reviewed for accuracy. National Student Clearinghouse issue notifications will also be kept on file for future reference. Contact person: Rich Kluin, Vice President – Finance and Operations, Southeast Technical College Status of finding – The above corrective actions will be implemented beginning July 1, 2024.

View Audit 301715

Finding 391126 (2023-003)

Significant Deficiency 2023

Sioux Falls School District 49-5

SD

Questioned Costs Student Financial Aid Subrecipient Monitoring

Identifying Number: 2023-003: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: For one student out of 61 students tested, an incorrect amount of subsidized and unsubsidized loan was awarded. Corrective Action Taken or Planned: STC Financial ...

Identifying Number: 2023-003: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: For one student out of 61 students tested, an incorrect amount of subsidized and unsubsidized loan was awarded. Corrective Action Taken or Planned: STC Financial Aid Office will request a list of Build Dakota students and estimated scholarship amounts at the beginning of the academic year. This information will be added into the student’s financial aid packaging formula to review for potential changes needed in federal aid awards. Once the Business Office has completed applying Build Dakota funds for the term, the information will be shared with the Financial Aid Office to make adjustments to the original estimates used. Contact person: Micah Hansen, Director of Financial Aid, Southeast Technical College Status of finding – The above corrective actions will be implemented beginning July 1, 2024.

View Audit 301715 Questioned Costs: $1

Finding 391123 (2023-010)

Significant Deficiency 2023

State of Iowa

IA

Subrecipient Monitoring

Effective August 2023, new sub-awards and pass thru grant agreements have elements specified in the respective agreement as required by Uniform Guidance, Part 200.332

View Audit 301710

Finding 391109 (2023-003)

Significant Deficiency 2023

State of Iowa

IA

Subrecipient Monitoring

The Department will follow policies and procedures in place for fiscal year 2023, to certify the amounts contributed annually and ensure discrepancies are followed up within 180 days. implemented a revised cash

View Audit 301710

Finding 391100 (2023-004)

Material Weakness 2023

Ninnekah School District I-51

OK

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Air conditioners were purchased by the district as part of the remodeling of the high school to go along with the bond issue. The purchase was made in good faith and the superintendent believed it to be within compliance of the bond issue. The district accepts that the actions were not in complian...

Air conditioners were purchased by the district as part of the remodeling of the high school to go along with the bond issue. The purchase was made in good faith and the superintendent believed it to be within compliance of the bond issue. The district accepts that the actions were not in compliance and will review policy and seek training opportunities to not make the same mistake in the future. All actions will be corrected by June 30, 2024.

View Audit 301693

Finding 391066 (2023-001)

Material Weakness 2023

Jefferson Local School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management

We will ensure wage records are obtained from contractors and subcontractors providing work over $1,999 to the District when paying with federal funds.

View Audit 301656

Finding 391024 (2023-001)

Significant Deficiency 2023

Okc Charter Santa Fe South Schools No. G-021

OK

Equipment & Real Property Management Subrecipient Monitoring

Finding Summary: Two inventory items were improperly assigned (entered) in the inventory system for the ESSER funds that should have been charged to the general fund. Corrective Action Plan: Controls are in place to ensure that the Inventory list provides the correct items that belong to the Federal...

Finding Summary: Two inventory items were improperly assigned (entered) in the inventory system for the ESSER funds that should have been charged to the general fund. Corrective Action Plan: Controls are in place to ensure that the Inventory list provides the correct items that belong to the Federal Award. We are adding two additional procedures to the inventory procedure document. 1. Run the summary expenditure report by the different Federal projects to verify it against the invoices paid. 2. Add the federal project items listed on the purchase order payment detail to ensure they match the items entered in the inventory system. Responsible Individuals: Alton J. Watson / Chief Technology Officer Maritza Santiago / Director of Finance Anticipated Completion Date: 3/27/2024

View Audit 301635

Finding 391019 (2023-001)

Significant Deficiency 2023

Newport County Community Mental Health Center, Inc.

RI

Subrecipient Monitoring Questioned Costs Reporting

Health Resources and Services Administration Newport County Community Mental Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. ____________________________________________________________________________ CohnReznick LLP 350 Granite Stre...

Health Resources and Services Administration Newport County Community Mental Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. ____________________________________________________________________________ CohnReznick LLP 350 Granite Street, Suite 1200 Braintree, MA 02184 Audit Period: June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. FINDINGS - Federal Award Program Audit Name of Federal Agency: U.S. Department of Health and Human Services Federal Program Name and Assistance Listing Number: Block Grants for Community Mental Health Services under ALN 93.958 Federal Award Identification Number and Year: H79SM085689, 2021-2023 Finding 2023-001 – Reporting Significant Deficiency We recommend that the Center strengthen their system of internal controls to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Action Taken Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency. In addition, Management will submit to the Federal funding Accountability and Transparency system the required reporting from fiscal years 2020 through 2023. If the Health Resources and Services Administration has questions regarding this plan, please call Dayna Gladstein, Chief Executive Officer at 401-846-1213.

View Audit 301623

Finding 391017 (2023-031)

Significant Deficiency 2023

State of Louisiana

LA

Questioned Costs Subrecipient Monitoring Reporting

Dear Mr. Waguespack: The Governor’s Office of Homeland Security and Emergency Preparedness (GOHSEP) hereby provides this response to the fiscal year 2023 single audit finding. As requested in your January 25, 2024 correspondence, please see the details of our response below: • This response is pro...

Dear Mr. Waguespack: The Governor’s Office of Homeland Security and Emergency Preparedness (GOHSEP) hereby provides this response to the fiscal year 2023 single audit finding. As requested in your January 25, 2024 correspondence, please see the details of our response below: • This response is provided for the revised finding, “Noncompliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA).” • GOHSEP concurs with the individual finding and recommendation: • While all FY23 FMA obligation entries were made into FSRS, GOHSEP concedes that the 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) is currently unable to use the FFATA reporting feature in GOHSEP Grants (system of record) to import the data into FSRS. • GOHSEP concurs 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. • Corrective Action Plan: o Persons responsible for corrective action: • Sandra D. Gaspard (Assistant Director, HMA) • Jeffrey Giering (Executive Officer, HMA) o Corrective Action Planned: • Identify additional HM staff that will be responsible for accurate and timely FSRS entry and reporting (prime contact plus support staff) • Access to Grants/Subgrants in FSRS: GOHSEP will work with FEMA and other Federal contacts as required to ensure all assigned staff have the proper access and permissions to edit all HMA grants/subgrants as necessary. • 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: • We estimate that the appropriate staff will have proper access to the FSRS within 30-90 days, depending on timeline of federal permissions approval. Data entry in the system will proceed via a manual process and will be monitored for timely entry, as per 2 CFR Part 170, Appendix A (I)(a). • Due to the need for technical assistance and potentially for funding for a system enhancement on the GOHSEP Grants portion, we estimate this will be complete in 90-180 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 301612

Finding 391001 (2023-023)

Significant Deficiency 2023

State of Louisiana

LA

Questioned Costs Subrecipient Monitoring

Dear Mr. Waguespack, The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 25, 2024, regarding a reportable audit finding related to controls over waiver and support coordination service providers at the LDH. The LDH app...

Dear Mr. Waguespack, The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 25, 2024, regarding a reportable audit finding related to controls over waiver and support coordination service providers at the LDH. The LDH appreciates the opportunity to provide this response to your office's findings. Finding: Inadequate Controls over Waiver and Support Coordination Service Providers Recommendation: LDH should ensure all departmental policies for waiver and support coordination services are enforced, including documentation to support claims and evidence that deviations from the approved POC meet the needs of the recipient. LDH should consider additional provider training regarding documentation requirements. LDH Response: LDH partially concurs with the finding and recommendation. LDH does not concur with the determination of inadequate controls over waiver and support coordination providers. LLA asserts inadequate documentation prohibits substantiating if deviations where person-centered and/or billed services were performed. A combination of factors and not documentation alone must be considered when determining whether billed services we performed or the services delivered are person¬-centered. A prioritization on documentation as assurance of services provided seem to disregard more effective, nationally recognized, and mandated assurance measures such as electronic visit verification (EVV), prior authorization, and post authorization. Assurance measures like those listed above gear more towards validating whether services were provided than documentation alone. For example, documentation such as progress notes is not intended to verify if a service was provided but summarize the beneficiary's day-to-day activities and demonstrates progress toward achieving his/her personal outcomes as identified in the approved plan of care (POC). Corrective Action Plan: LDH does concur with LLA's recommendation regarding policy enforcement measures and additional provider training. Given the high turnover due to the national direct support worker and support coordinator workforce crisis, as well as the end of COVID-19 public health emergency, we agree with the need for robust training and additional oversight/policy enforcement. Therefore, LDH will develop action steps to address the need for additional provider training and action steps to provide additional oversight policy enforcement. The anticipated completion date of all corrective action is March 30, 2024. You may contact Bernard Brown, Deputy Assistant Secretary, by telephone at 225-342- 8807 or by e-mail at bernard.brown@la.gov with any questions about this matter.

View Audit 301612 Questioned Costs: $1

Finding 390972 (2023-021)

Significant Deficiency 2023

State of Louisiana

LA

Questioned Costs Subrecipient Monitoring

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated December 12, 2023, regarding a reportable audit finding related to billing controls for behavioral health services. LDH appreciates the opportunity to pr...

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated December 12, 2023, regarding a reportable audit finding related to billing controls for behavioral health services. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over Billing for Behavioral Health Services. Recommendation: LDH management should ensure that agency personnel are adequately monitoring the EQR contract and that the proper validations are being conducted to ensure encounters are coded correctly. LDH Response: LDH concurs. Corrective Action Plan: LDH will continue to refined the scope of the EQRO review and adjust as needed. Additionally, LDH will continue to monitor our EQR contract to ensure we are able to identify encounters that the MCEs paid at an inappropriate rate given the unique provider, their credentials, service location and the confirmation of the appropriate Medicaid fee schedule or alternative rates against which claims were to be processed. LDH has worked diligently to both identify instances when encounters that appear to have not been paid in accordance with the SBHS fee schedule were, in fact, paid at the appropriate rate, as well as, reduce the volume of encounters that truly are reflective of improper claims' processing. While SBHS expenditures have increased by approximately 16% since the initial FY19 finding, the number of encounters identified in the FY23 report have decreased by more than 83% over that same period. LDH is committed to this ongoing initiative, and intends to continue the supplemental EQR protocol in an effort to further reduce the inaccurate identification of improperly paid claims, as well as requiring the MCEs to ensure their claims processing systems are functioning appropriately or are updated, as indicated based upon applicable EQR findings. You may contact Karen Stubbs, OBH Assistant Secretary by telephone at (225) 342-1435 or by e-mail at karen.stubbs@la.gov with any questions concerning this matter.

View Audit 301612

Finding 390934 (2023-008)

Significant Deficiency 2023

State of Louisiana

LA

Subrecipient Monitoring § 200.332

Dear Mr. Waguespack. Please find below our management response to the audit finding "Noncompliance with Subrecipient Monitoring Requirements". The University concurs with the finding results that from a sample of seven subawards out of a population of 43 subawards, five (71.4%) of the subrecipient...

Dear Mr. Waguespack. Please find below our management response to the audit finding "Noncompliance with Subrecipient Monitoring Requirements". The University concurs with the finding results that from a sample of seven subawards out of a population of 43 subawards, five (71.4%) of the subrecipients evaluated, the University could not provide evidence that the financial and performance reports required by the subaward agreement were obtained and reviewed, and two (28.6%) of the subrecipients evaluated, the subaward documents did not contain the Assistance Listing (AL) number and/or the federal award date, as required by federal regulations. The Sponsored Programs Finance Administration and Compliance office (SPFAC) is committed to correcting these two deficiencies by working with our Principal Investigators to secure copies of the subaward technical and financial reports before they are incorporated into the final version of the report submitted to funder where applicable. This step will be included in the department's standard operating procedures. To prevent missing entering important award information like the AL number and or the federal award date, as required by federal regulations, SPFAC will facilitate a refresher training to its Post Award team on how to complete the sub award agreements and documentation in accordance with federal regulations. The director of SPFAC will oversee the implementation of this action plan.

View Audit 301612

Corrective Action Plans

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