Corrective Action Plans

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has received the finding titled “Weakness in Controls over Payroll.” The finding noted DCFS employees and supervisors did not timely certify and approve time and attendance records and supervisors did not approve or reject leave requests before the end of the applicable pay period. Although DCFS has procedures in place for both the employee and appointing authority or designee to approve, reject, and certify payroll and attendance records by utilizing the electronic time sheets in the Cross-Application Time Sheets (CATS) system, we concur with the finding that some were not completed timely. DCFS continuously strives to improve processes and controls and has taken corrective action. As part of our continuous improvement plan, we provided time administrators with instructions and reminders on how to review the eCertification Report (ZP241) in LaGov HCM each pay period to identify time statements that have not been certified and approved and to provide appropriate follow up with staff. DCFS Human Resources will continue to send periodic notices to all DCFS employees regarding the eCertification process including a reminder of the importance of all employees being vigilant and compliant in completing the process to ensure time reporting is accurate and complete. The contact person for Payroll is Marion Creft-Jackson, Human Resources Supervisor, and she can be reached at (225) 342-3146 or Marion.Creft-Jackson.DCFS@la.gov.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 7, 2024, regarding a reportable audit finding related to inadequate controls over payroll for the following programs in the Office of Public Health (OPH): Public Health Emergency Preparedness (PHEP) and HIV Prevention Activities (HIV). LDH appreciates the opportunity to provide this response to your office's finding. Finding: Inadequate Controls over Payroll - OPH Recommendation: OPH should ensure employees comply with existing policies and procedures, including properly certifying and approving electronic time statements. LDH Response: LDH concurs with the finding and concurs with the recommendation. Corrective Action: As part of a comprehensive agency-wide plan to address this finding, OPH is developing a corrective action plan to enact control measures and monitor the certification and approval of electronic time statements. The below corrective measures have been put in place or will be put in place to prevent future findings. OPH implemented an updated Time Entry Policy in place in April 2023. This policy includes employee, supervisor, and time administrator responsibilities regarding the certification and approval of electronic time statements. This policy will be redistributed agency wide. Each pay period, LDH Human Resources sends all LDH and OPH time administrators an email containing Time Administrator payroll timelines and reports that must be run each pay period. Included are reports indicating errors requiring corrections prior to payroll close and the eCertification Report used to identify any electronic time statements that have not been certified or approved for follow-up. Each pay period, LDH Human Resources emails the OPH Assistant Secretary reports of time statements not certified and/or approved. These reports are sent to all areas of OPH to ensure corrective measures are taken. OPH will also set earlier internal deadlines for employees and supervisors to certify and approve their timesheets. This will allow Time Administrators to run reports sooner to identify electronic time statements that have not been certified or approved and allow time for follow-up. OPH will implement a new procedure requiring Time Administrators to conduct an orientation with any new hires or transfers within the first week of hire or transfer. The Time Administrator will review the entry of time, the entry of leave requests, and the deadlines for approval and certification. You may contact Devin George, Deputy Assistant Secretary, by telephone at (225) 342-2655, or by email at devin.george@la.gov.

Dear Mr. Waguespack, Thank you for the opportunity to respond to your office's finding related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the concerns/issues identified by your staff. LSUHSC-S concurs with the recommendation for addressing the finding and provides the following response and corrective action plan. Recommendation: Management should monitor, investigate, and obtain justification from department personnel for untimely time and effort certifications, untimely adjustments, and lack of supporting documentation for adjustments to enforce established policies. Response and Corrective Action Plan: To continue to strengthen the institutional internal controls within award management, LSUHSC-S is addressing the organizational structure. LSUHSC-S historical organizational structure reflects the award management of grants administration and grants accounting functions separately. In contrast, the prevailing model at peer institutions is centralized management, aiming to enhance communication and transparency across grants administration and finance. In response, LSUHSC-S is actively taking steps to consolidate these functions under joint authority. The chancellor has approved an organizational restructuring of award management resulting in the creation of the Office for Sponsored Awards Management (SAM). This office will operate under a Director reporting jointly to the Vice Chancellor for Research and Chief Financial Officer. The institution is initiating the recruitment of a SAM Director and Associate Director of Grants and Contracts Accounting to further strengthen the research infrastructure. In addition, the following processes are under revision and /or implemented to enforce award management requirements. Time and Effort Reporting. LSUHSC-S Administrative Directive 4.4: Time and Effort Reporting and Certification will be updated to reflect the on-line process that is being developed through our Peoplesoft IT Group and with the LSUHSC- New Orleans functional users. Once operational, Office for Sponsored Awards Management (SAM) will evaluate the time and effort reporting procedures, along with associated forms used to report supporting evidence, ensuring accurate documentation and recertification of time and effort for each personnel action as reported on active grants. SAM will also monitor and maintain time and effort certifications to ensure alignment of cost transfers with award terms. Cost Transfers. Effective July 2023, LSUHSC-S implemented new policies, specifically Administrative Directive 1.1.8: Closing Out Grants and Contracts and Administrative Directive 1.1.9: Elimination of Grants and Contracts Account Overdrafts, outlining procedures to facilitate the closure of grants and contracts accounts and to eliminate overdrafts within such accounts. These directives include the establishment of a matrix detailing responsibilities and timelines for closing out grants. The policies offer procedural guidance to rectify overdrafts beyond the approved budget. A feature in PeopleSoft is activated to restrict personnel expenditures exceeding budget limits or extending beyond the performance period. Such expenditures are recorded in a suspense account, subject to review by departmental business staff for the identification of alternate funding sources. To prevent non-personnel expenditures beyond the performance period, LSUHSC-S assigns end dates to sponsored awards. Training. LSUHSC-S continues to conduct and improve training sessions and educational meetings that cover federal, state, and institutional requirements. Mandatory annual training for all employees involved or planning to engage in research includes a module on time and effort certifications and expense monitoring. In addition to the annual training, supplementary education consists of one-on-one departmental meetings held by the Office for Sponsored Programs, continuing education for department business managers and administrative staff, and specialized sessions designed for research personnel. Examples of such educational opportunities include a New Grant Award Meeting and additional training sessions publicized in the Research Matters Newsletter. Emphasis is placed on grant management organizational podcasts and classes for seasoned and new business staff, principal investigators, and institutional grant and contract support staff. Name of Contact(s) Responsible for Action Plan Marcia Scarmardo, Chief Advisor to Chancellor Jen Katzman, Assistant Vice Chancellor for Administration and Finance (with Departmental Business Managers) Bill Haacker, Assistant Director of Grants Accounting Steven McAlister, Associate Director of General Accounting Annella Nelson, Assistant Vice Chancellor for Research Development Anticipated Completion Date: Continuous If you have questions or require additional information, please contact me at (318) 675-5230 or via email at cindy.rives@lsuhs.edu.

Dear Mr. Waguespack: Please find below our management response to the audit finding "Control Weakness and Noncompliance with Personnel Expenses Charged to Federal Awards.” The University concurs with the finding results. As you may recall, FY 22's finding prompted us to create an effort reporting policy and system in draft mode and tested it starting at the end of FY 22 and FY23. This audit has brought to the attention of the office of Sponsored Programs Finance Administration and Compliance (SPFAC) that there are deficiencies in our adopted system, particularly in the generation of effort reports, which regrettably missed some key personnel and required information. Your identification of these shortcomings underscores the urgency of our need to enhance our internal controls and procedures to ensure compliance with federal regulations. Regarding the draft policy calling for quarterly effort reports, we have carefully considered your recommendation and in light of our operational capacities have decided to proceed with an annual, calendar year (CY) reporting time frame. We believe that an annual reporting cycle aligns better with our current operational resources. We will ensure that this chosen reporting cycle is rigorously adhered to and supplemented with additional measures as needed to enhance accuracy and timeliness. Moving forward, we are committed to the following actions to address the identified deficiencies: 1. Enhancing Internal Controls: We will review and strengthen our internal control framework to ensure that all required information is captured accurately and comprehensively in our effort reports. 2. Annual Time & Effort Certification: We will revise our Time & Effort Certification policy to reflect the decision to adopt an annual reporting time frame. This will involve refining our processes to ensure that annual certifications provide a thorough and accurate reflection of personnel effort on federal awards as required by federal regulations. The annual reports will be processed on a calendar year (CY) basis. To allow for a fresh start for CY 2024, the next effort reporting cycle will cover July 1, 2023, through December 31, 2023. 3. Monitoring and Oversight: We will establish robust monitoring mechanisms to track changes in personnel effort and ensure that any deviations from approved thresholds are promptly identified and addressed. To further assist with correction of this finding, the University has engaged Ellucian Banner to apply the Effort Certification Module which is a systematic certification process for us to review, validate and certify the work effort performed by faculty and staff in support of sponsored research. The module is expected to go in test mode in 2024 and anticipated to go live in 2025. The director of SPFAC will oversee the implementation of this action plan.

Audit Finding Reference: 2023-004 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking due to the employee longer working in the district. The grant manager did verify that the employee worked the hours noted, but lacks the employees’ signature. This is not a typical occurrence Time and Effort is used and submitted. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Procedure has changed a reminder will be communicated by March 30th.

Item 2023‐001 – Allowable Costs/Activities Contact person: Wendy Stephens, Senior Accounting Manager Management’s Response – Management’s controls over approval of time sheets operated effectively 97.5% of the time prior to processing of payroll. The payroll expenditures allocated to the COVID-19 Provider Relief Fund – Assistance Listing 93.498 were allocated to the Provider Relief Funding and including in reporting of expenditures based on management review of guidance provided by HRSA in determination of the portion of the payroll costs allocated as qualifying and allowable expenditures under the program. The guidance on allowable costs was determined by HRSA subsequent to disbursement of the funds by HRSA and after incurrence of the expenditures given the immediacy of the COVID-19 pandemic providing of funds and incurrence of costs. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management’s controls over approval of time sheets operated effectively 97% of the time prior to processing payroll. The payroll expenditures related to the 1 time sheet not approved prior to payment of payroll are for an employee assigned to work specifically on the program funded by Assistance Listing #93.778. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management expects the corrective actions described above to be complete no later than June 30, 2024.

REFERENCE: 2023-003 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long Beach and Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At St. Mary Medical Center – Long Beach, the leadership team implemented a timecard review process to ensure timecards are properly signed off and approved each pay period, with exceptions confirmed via email from the appropriate manager. At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders will be sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator will send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The executive director will ensure supervisory follow-up with each name that shows up in the audit report each pay period by Kronos Reports. Person Responsible: Vo Phay Sin, Controller – St. Mary Medical Center, Long Beach Rob Hays, Executive Director – Bailey Boushay House Expected Completion: April 2024

REFERENCE: 2023-002 – Allowable Costs/Cost Principles Medical Assistance Program (Medicaid Cluster) (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Mercy San Juan Medical Center Finding: At Mercy San Juan Medical Center, internal controls over the required allowability criteria with regard to payroll expense were not performed for 2 of 25 employees selected for testing. Corrective Action Plan: In addition to timecard approval by supervisors, Mercy San Juan Medical Center Finance will review a sign-off report and obtain written approval via email for unapproved timecards. Person Responsible: Lianna Petrosyan, Director of Finance Expected Completion: April 2024

Finding Reference Number: SA2023-002 Documenting Payroll Costs Charged to Grant Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0010 COVID-19 - B-20-MW-06-0010 • Fiscal Year of Initial Finding: 2023 • Name(s) of the contact person: Betsy ZoBell, Housing and Community Development Manager • Corrective Action Plan: ECD staff will perform periodic review of estimates to confirm that payroll allocations are supported by timesheet documentation of actual hours worked. • Anticipated Completion Date: 06/30/24

Finding Number: 2023‐001 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425U, 84.425W Contact Person: Andrea Leon Foster, Director of Federal Programs Anticipated Completion Date: June 30, 2024 Planned Corrective Action: Although the Federal Programs Department has a process for periodic certification, compression was not included in the percentage breakdown for each classified staff salary. Reporting adjustments have been made to include ESSER funded positions with additional oversight  on  percentage  breakdowns  for  positions  funded  with  multiple  cost  objectives.  These  breakdowns are reflected in the electronic version of FORMS B and D in addition to the hard copies. The  Federal  Programs  Director  will  work  with  district  leadership  to  ensure  all  employees  in  each  department (Curriculum and Instruction, Professional Development, etc.) on the process of maintaining Time and Effort logs and signing the bi‐annual FORM B and FORM D.

The district Information Technology Services unit is currently working with Ellucian to configure and implement the Time and Effort reporting module within the BANNER timekeeping system. This will allow departments to monitor time and effort activity and ensure that allowable costs are tracked and charged to the appropriate programs and services. This should be completed by June 30, 2024.

Finding #2023-001: Reconciliation of Allocated Costs CLIENT PLANNED ACTION: Hospital Sisters Health System agrees with the finding and will reevaluate the procedures in place to reconcile all costs allocated to grants. We will implement processes to ensure that all costs are substantiated with appropriate supporting detail and are reconciled and reviewed in a timely manner. CLIENT RESPONSIBLE PARTY: Steve Canny, System Director-Financial Reporting, Compliance & Internal Control COMPLETION DATE: We anticipate having these procedures in place by June 30, 2024.

NOTE: While discrepancies in payroll entries were observed during the period of emergency declaration, which provided full flexibility in fund usage, it's important to note that this doesn't justify inconsistencies between timesheets and the general ledger. The CFO will immediately evaluate the procedures involved in recording employee time on timesheets and transferring this data to the financial management system. The CFO will immediately evaluate the need for additional controls to ensure accurate recording of time charged to programs as reflected on the employee's timesheet. The CFO will immediately implement new processes that establish checks and balances to verify that the programs charged in the general ledger align with the time recorded by the employees and is verified by their supervisor. The CFO and HR director will provide training sessions to all staff and new hires on the importance of accurately capturing and recording payroll costs by April 30, 2024. The CEO will immediately provide training to the CFO and staff accountant on the significance of aligning time charged with the programs designated in the general ledger for proper grant award billing. The CFO will conduct periodic reviews of payroll transactions to identify any discrepancies or irregularities promptly and take action immediately upon identification of such. These reviews will continue through FY 2025.

Finding 2023-003: Inadequate Documentation of Employee Time and Effort Allocation for Federal Program Identification of the Federal Program: Assistance Listing Number 17.259 - WIOA Youth Activities Program - U.S. Department of Labor. Pass-through Entity: New York City Department of Youth and Community Development. Award Number: 90535A / 90536A / 90537A / 90538A. Compliance Requirement: Allowable Costs/Cost Principles. Criteria: Requirements per section 2 CFR Part 200.430 of the Uniform Guidance state that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed and be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: During our testing for the year ended June 30, 2023, we noted a lack of detail for employee's actual hours spent on different programs. Time and effort are allocated based on budgeted amounts. Cause: Allocation to funding sources was entered into the payroll system based on budgeted estimates rather than actual time records. Effect or Potential Effect: The lack of contemporaneous documentation of employee hours worked by grant or federal program could allow the Organization to improperly allocate employee pay to federal grants. Questioned Costs: $65,379 Context: As most employees work specifically on a single program, there was only one employee that worked on multiple programs for which time spent on the program could not be substantiated. The total questioned cost allocated to the program for this person totaled $65,379. Plan: 1. Mandatory Time and Program Effort Records: OBT has implemented allocations by program in our payroll software. Hourly employees allocated to multiple programs will clock in and out for each program and all timecards are approved by management. Reports are reviewed every payroll for accuracy. 2. Training: OBT has provided training to all employees on the importance of accurate time and effort reporting for federal programs, ensuring that employees understand the requirements and their responsibilities in maintaining these records. 3. Internal Controls: OBT has implemented internal controls to review and verify the accuracy of time and effort records, ensuring that charges to federal awards comply with regulations. 4. Monitoring and Auditing: OBT conducts regular monitoring and internal audits to validate the accuracy and completeness of time and effort records. Name of Contact Person: Carla Licavoli, Chief Operating & Compliance Officer Target Date: OBT implemented all four steps within this plan by December 31, 2023, with ongoing monitoring and improvement.

Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are standard practice in our organization were not being completed. In addition, the filing of certain documentation to support expenditures was not being done consistently. The Director of Finance position was not filled until November 2022. As a result, documentation of allowable expenditures is being addressed for the fiscal 2023 audit. In addition to turnover, the organization transitioned to a new general ledger system with a new chart of accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certain data pertaining to the federal programs was not being captured. Management has informed all staff of the requirements to track federal programs within the general ledger accounts. Anticipated Completion Date: September 30, 2024 Responsible Contact Person: Erica Tkachyk, Director of Finance

Charter School Program - Assistance Listing No. 84.282 Recommendation: We recommend the School ensure policies and procedures for payroll expenditures for grant programs be charged to the federal grant based on approved hours worked in the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Options Schools, Inc. will implement policies and procedures for payroll expenditures charged to federal grant programs that track approved time worked. Name(s) of the contact person(s) responsible for corrective action: Jack Colwell Planned completion date for corrective action plan: July 1, 2023

This was noted in last year's audit but was identified late in the fiscal year. The time required to do the due diligence and implementation was part of our timesheet review system was not fixed until after June 2023. As noted in last year's goal, Sewall administration completed a review of payroll companies and committed on a new system that began in October 2023. Along with that, we have organized a new internal system of tracking staff's time given the complexities of the many blended funding sources. We have also implemented a regular review and supervision of time sheet allocations.

The payroll allocation process was adjusted during the fiscal year following the transition that created both the fiscal year 2022 and 2023 findings. This process has also been reviewed by NSF. A system of checks and balances are also in place to make sure wages are accurate between files and the payroll system. Person(s) Responsible: Gina Grange Timing for Implementation: Complete

ection IV – Corrective Action Plan Finding 2023-001 Programs: LIFF Grant Significant Deficiency over Financial Reporting Repeat Finding: No Auditee’s Corrective Action Plan: In the future, when payroll data is imported from ADP, we will include LiFF grant code to track costs on the accounting system. This is implemented for non-payroll related costs. Contact Person: Berhane Ayichew

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Sarah Haven, Director of Finance & Operations Corrective Action: The Winooski School District will implement the following to address finding 2023-001 Implement control processes and procedures to ensure that time certifications are accurate and complete. Anticipated Completion Date: 6/30/2024

A/B. Allowable Costs and Cost Principles/Activities Allowed or Unallowed Administrative Cost Grants for Indian Schools FFAL #15.046 Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: During the course of the engagement, Eide Bailly identified four expenditures where payroll was not paid in accordance with employment letter. Corrective Action Plan: Anticipated Completion Date: The School will review internal controls surrounding allowable costs and activities to ensure they are adequate to identify unallowable expenditures. June 30, 2024

A/B. Allowable Costs and Cost Principles/ Activities Allowed or Unallowed Indian School Equalization FFAL #15.042 Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: During the course of the engagement, Eide Bailly identified five expenditures Corrective Action Plan: Anticipated Completion Date: where payroll was not paid in accordance with employment letter. The School will review internal controls surrounding allowable costs and activities to ensure they are adequate to identify unallowable expenditures. June 30, 2024

2023-004 FINDING: INADEQUATE CONTROLS OVER PAYROLL EXPENDITURES AND NONCOMPLIANCE WITH ALLOWABLE COST & COST PRINCIPLES REQUIREMENTS APPLICABLE TO THE HEAD START CLUSTER Corrective Action Plan: The University has updated its process to collect time and effort information on a semi-annual basis rather than quarterly, which relieves some burden from staff, but still complies with federal regulations. By collecting time and effort information on a semi-annual basis, staff will have more time to reconcile time and effort against actual payroll expenditures. The University has also redesigned the time and effort collection form to show the 100% distribution of work. Further, the University now has a full-time financial research administrator who will help ensure that payroll related adjustments are done timely. The financial research administrator will work with the Early Head Start program management to ensure that the related payroll reports are reviewed and reconciled timely, in accordance with existing University procedures. Responsible University Personnel: Erin Soto, Executive Director of Family Development Center; FeMia Norwood, Director of Office of Sponsored Programs and Research; Jessica Braddy, Financial Research Administrator. Anticipated completion date: Already implemented.

Department: Administrative and Financial Services Title: Internal control over monitoring of employee classification and compensation needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The department will allocate resources to adhere to the statutory review of the classification specifications--a timeframe which as of 2024 is every 10 years. The department will continue to document reviews of classifications specifications, including those which do not result in changes. The department will create and maintain a spreadsheet to record all reviews of classification specifications. Completion Date: June 30, 2024 Agency Contact: Breena Bissell, Director, Bureau of Human Resources, DAFS, 207-624-7368

Planned Corrective Action: Meals on Wheels of the Monterey Peninsula (MOWMP) will address the finding by taking the steps outlined below: 1. Expenditure Allocation: Controller and/or bookkeeper will allocate expenditures based on the number of meals prepared each month and the percentage of meals prepared for each program and funding. Yearly reviews of the allocation process will be conducted to ensure accuracy and relevance. Adjustments may be made based on changes in meal demand, program requirements, funding sources, or other factors affecting meal preparation costs. 2. Payroll Reporting: On a yearly basis, Managers and/or Directors will allocate the amount of time each employe works based on tasks performed and the amount of time worked on federal award activities. This allocation will be expressed as a percentage of total work hours performed. Periodic adjustments to time allocations may be necessary to reflect changes in project priorities, staffing levels, or other factors affecting workload distribution. Person Responsible for Corrective Action Plan: Leadership Oversight – Christine Winge, Executive Director Operational Oversight – Kay Smith, Controller Anticipated Date of Completion: MOWMP will complete the Corrective Action Plan by June 1, 2024. We will implement the Corrective Action Plan beginning July 1, 2024.