Corrective Action Plans

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated March 8, 2023, regarding a reportable audit finding related to Inadequate Controls over Payroll. This finding pertains to the following programs in the Office of Public Health (OPH): Special Supplemental Nutrition Program for Women, Infants and Children (WIC), Public Health Emergency Preparedness (PHEP), Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), and HIV Prevention Activities (HIV). LDH appreciates the opportunity to provide this response to your office's finding.Finding: Inadequate Controls over Payroll - OPHRecommendation: OPH should ensure employees comply with existing policies and procedures, including certifying and approving electronic time statements in a timely manner.LDH Response: LDH concurs with the finding and concurs with the recommendation.As part of a comprehensive agency-wide plan to address this finding, OPH has developed a corrective action plan to enact control measures and monitor the certification and approval of electronic time statements.OPH has a Time Entry Policy in final draft form that will be in place and distributed to all staff by March 24, 2023. This policy includes employee, supervisor, and time administrator responsibilities regarding the certification and approval of electronic time statements.OPH has a new compliance position, and will be reviewing compliance of policies and procedures across the agency. Controls over payroll, including the electronic certification and approval of time statements, will be one of the areas of focus for this position. The position will be filled on March 20, 2023.Each pay period, LDH Human Resources sends all LDH and OPH time administrators an email that includes Time Administrator Payroll Timelines and reports that must be run each pay period. This also includes reports that indicate errors that must be corrected 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.LDH Human Resources has in-person trainings currently scheduled for LDH and OPH time administrators across the state.You may contact Devin George, OPH Deputy Assistant Secretary, by telephone at (225) 342-2655, or by email at devin.george@la.gov.

Dear Mr. Waguespack:Below is the Law Center's response to the Finding ' Improper Payments to Southern University Law Center Employee".FINDING: Improper Payments to Southern University Law Center Employee " .RESPONSE:Southern University Law Center (SULC) concurs with the finding on Improper Payments to Southern University Law Center Employee.SULC has taken the following steps to ensure that an employee' s employment status is revised immediately to prevent such occurrences in the future. With respect to employee notices of resignations, retirements , or other terminations (terminations) , SULC will perform the following procedures.1. Establish a line of communication with specific Human Resource (HR) personnel addressing terminations of employees, including EPAF processing.2. Establish a timeline for EPAF processing.3. Immediately notify the web-time payroll approver, Supervisor and or Director, and Vice Chancellor for the department of the employee's terminal employment status.Terry R. Hall, Vice Chancellor for Finance and Administration will be responsible for the corrective action plan. Procedures for the correction plan have been initiated and will be fully operable during the fiscal year 2022-2023.

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 does not concur that this is a second consecutive year finding, but in fact the same one from FY2021.The completion of FY2021 audit and the start of FY2022 audit did not allow the University time in between to correct the FY2021 finding.The following is timeline for the FY2021 finding.? Notification of potential finding was sent on 4/20/22.? Preliminary response request was sent on 5/26/22.? Preliminary finding response was submitted on 6/2/22.? Audit response request letter was sent on 6/6/22.? Audit response was submitted on 6/10/22.Sponsored Programs Finance Administration and Compliance (SPFAC) will continue the following corrective action provided in FY2021 and it will be overseen by Director of SPFAC.1. Update the current effort reporting and certification policy.2. Create and implement an internal user-friendly effort reporting system.3. Train faculty and staff on how to use the effort reporting and certification system.4. Track the effort certifications quarterly.5. For federal awards that follow CFR 200.201- Use of grant agreements (including fixed amount awards), cooperative agreements, and contracts, the University will internally track and certify the personnel effort cost separately as the billing is dictated by the issued task orders based on the estimated task order cost.

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 issues identified by your staff. LSUHSC-S concurs with the recommendations to address the finding and provides the following response and corrective action plan.Recommendation:Management should monitor time and effort certifications completed by the departments and investigate and obtain justification from department personnel for untimely certifications as well as untimely adjustments and lack of supporting documentation for the adjustments to enforce established policies.Response and Corrective Action Plan:LSUHSC-S will continue to offer training classes and educational meetings to address the Federal requirements and ensure compliance. The training classes include one-on-one departmental meetings held by the Office of Sponsored Programs on new awards, Department Business Manager and Administrative Staff monthly meetings, and research personnel time and effort educational sessions. Emphasis will be placed on grant management organizational podcasts and classes for seasoned and new business staff, principal investigators, and institutional grant and contract support staff.LSUHSC-S will again review the procedures to address improvements for processing adjustments through PERs with sufficient justification and timely approvals and entry in Peoplesoft.Name of Contact(s) Responsible for Action PlanSheila Faour, CFO, Business and ReimbursementsJen Katzman, Assistant Vice Chancellor for Administration and Finance (with Departmental Business Managers)Bill Haacker, Assistant Director of Grants AccountingSteven McAlister, Associate Director of General AccountingAnnella Nelson, Assistant Vice Chancellor for Research DevelopmentAnticipated Completion Date: ContinuousRecommendation:Management should ensure adequate design and operating effectiveness of controls over expenses, including P-Card expenses, charged to federal awards to verify allowability of costs in accordance with federal requirements and grant terms and conditions prior to requesting reimbursement.Response and Corrective Action Plan:The transaction exceptions identified totaled approximately $1,200 with one transaction exceeding the allocated budget and two transactions being coded to an incorrect award number.To address the exceptions, LSUHSC-S is exploring implementation of additional Peoplesoft module vendor transaction utility, such as adding more approvers and requiring additional description of the purchase to assist the applicable departments in fulfilling their responsibilities in the transactional review area.LSUHSC-S will also add this responsibility role training as part of our continuing one on one meetings and educational classes.Name of Contact(s) Responsible for Action PlanSheila Faour, CFO, Business and ReimbursementsJen Katzman, Assistant Vice Chancellor for Administration and Finance (with Departmental Business Managers)Steven McAlister, Associate Director of General AccountingBill Haacker, Assistant Director of Grants AccountingAnnella Nelson, Assistant Vice Chancellor for Research DevelopmentAnticipated Completion Date: ContinuousRecommendation:Management should also consider implementing other complementary controls such as preventing costs from being charged to projects in the accounting system beyond the approved budget or period of performance.Response and Corrective Action Plan:LSUHSC-S has implemented a setting in Peoplesoft that prevents personnel expenditures on accounts over budget or beyond the performance period. The personnel expenditures are captured in a suspense account for review by departmental business staff to identify the appropriate funding. This setting will be expanded for more projects and non-personnel expenditures.Name of Contact(s) Responsible for Action PlanSheila Faour, CFO, Business and ReimbursementsJen Katzman, Assistant Vice Chancellor for Administration and Finance (with Departmental Business Managers)Steven McAlister, Associate Director of General AccountingBill Haacker, Assistant Director of Grants AccountingAnticipated Completion Date: June 30, 2023If you have questions or require additional information, please contact me at (318) 675-5230 or via email at cindy.rives@lsuhs.edu.

REFERENCE: 2022-007 ? Allowable Costs/Cost PrinciplesHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoVirginia MasonFinding: At St. Mary?s Medical Center ? San Francisco and Virginia Mason, controls over the requiredallowability criteria with regard to payroll expense were not performed and/or documented throughout the year.Corrective Action Plan: This finding has been corrected. At St. Mary?s Medical Center ? San Francisco, as of July2021 invoices were prepared using actual payroll as opposed to budget. At Virginia Mason, beginning in April 2022,managers receive notification from the payroll department of unapproved time cards that are waiting for approval.A reminder email is sent to managers and employees to approve and submit their time cards on time. Trainingsessions were implemented to instruct all employees and the managers of this requirement. Once the training hasbeen completed and employees or managers miss approving the timecard then disciplinary actions will be taken.Payroll sends out messages of outstanding timecards awaiting approval.Person Responsible: Doug Amarelo ? St. Mary?s Medical Center, San FranciscoRebecca Kiser ? Virginia MasonCompletion: April 2022

REFERENCE: 2022-015 ? Allowable Costs/Cost PrinciplesMedical Assistance Program (Medicaid Cluster) (93.778)Federal Grantor: U.S. Department of Health and Human ServicesFacility: Dignity Health Connected LivingFinding: At Dignity Health Connected Living, internal controls over the required allowability criteria with regard to payroll expense were not performed for 1 of 25 employees selected for testing.Corrective Action Plan: In addition to timecard approval by supervisors, Dignity Health Connected Living finance will review a TEAMs salary report to review that time charged to the grant is accurate and appropriate. Review will be completed on a payperiod basis.Person Responsible: Marcela Ashinhurst, Senior Financial AnalystExpected Completion: April 2023

REFERENCE: 2022-008 ? Activities Allowed or UnallowedResearch and Development Cluster (Multiple)Federal Grantor: U.S. Department of DefenseU.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Corrective Action Plan: On a quarterly basis, program managers and grant managers meet with the principal investigator on all of their federal grants. During the meeting, the actual hours for all individuals are reviewed. Additionally, a reconciliation of actual to budget is performed. Documentation of the quarterly reviews is maintained on a google shared drive. Clinical time for federal grants will be supported by a completed timesheet signed by a supervisor or PI. Timesheets will be completed monthly.Person Responsible: Research Ops Managers; Tomas Cortez, Grant Accounting ManagerExpected Completion: September 2022

Finding: 2022-035 - Seven of 25 timesheets that charged FY 22 personal services to the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) program were not supported in compliance with federal requirements.Questioned Costs: $9,778Assistance Listing Number: 93.323Assistance Listing Title: ELCViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding. Corrective Action (corrective action planned): The division will ensure that all long-term, non-perm employees receive the same training as permanent employees on positive time keeping and how to complete a timesheet. Trainings will be completed within one week on hiring. All staff coding time to ELC grants will be required to send timesheets to the Director?s Office Admin staff for review monthly to ensure coding is done correctly.Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2023.Agency Contact (name of person responsible for corrective action): Josephine Stern, Assistant Commissioner

FINDING 2022-001Contact Person Responsible for Corrective Action: Allison Pund and Melissa BoeglinContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ensurecompliance with the Allowable Costs/Cost Principles compliance requirement. The Corporation will do so by maintainingadequate time records, to insure the proper amount was charged to the Federal Awards.Anticipated Date of Completion: March 2023

FINDING 2022-005Contact Person Responsible for Corrective Action: Robin Popejoy/Kim DeVaneyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustment have been made.As this finding is in review of ESSER funding, it should be noted that most all guidance and direction for these grantscame after they were issued. All financial transactions related to grants will have board oversight and approval.Anticipated Completion Date: February 2023

FINDING 2022-003Contact Person Responsible for Corrective Action: Kim DeVaney/Robin PopejoyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustments have beenmade. To prevent errors the Payroll Specialist will make sure the employee timesheets that was signed off by the Directormatches with the hours they were approved to work when hired.Anticipated Completion Date: February 2023

Recommendation: We recommend that the College increase the time and effort certification process to be more timely and implement a review process over the time and effort certification process.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action in Response to Finding: The College will implement the change to conduct the time and effort certification process semi-annually and to add an additional review by the Department Chair or Program Director, or in cases in which the PI is chair, the Dean of the Faculty.Name of the contact person responsible for corrective action: Tess Powers, Director of Faculty Research Support (719) 389-6318Planned completion date for corrective action plan: May 1, 2023

Finding 2022-003Material weakness in internal controls over compliance for allowable activities and costs and material non-compliance inthe Coronavirus State and Local Fiscal Recovery Fund program.Contact Person(s):Nicholas Lee, Chief Financial OfficerCorrective action planned:The Organization will provide additional training to employees responsible for incurring costs in accordance with 2 CFR200.403. Additional resources have been assigned to review and ensure documentation and policies are retained to supportthe distribution of charges between projects. Anticipated completion date:June 30, 2023

The District has implemented procedures for time and effort

Recommendation: The auditors recommend the University implement an internal control policy that requires employees whose compensation is charged to a federal award complete time and effort reporting to accurately reflect the work performed on each federal award and ensure supporting documentation is maintained for those who do charge time.Planned Corrective Action: Heritage University agrees with the finding. Heritage University will implement a new internal control policy that requires employees whose compensation is charged to federal awards to complete time and effort to accurately reflect the work performed on each federal award. Heritage University is using the time and effort forms to allocate the correct hours to each federal award during the payroll process period. Each time an employee must fill out the time and effort to show actual hours worked, signed by the employee and supervisor before turning it into the payroll department. Email sent out to all employees outlining the new process required by employees whose hours are charged to a federal award.Name of Responsible Party:1. Alysia Stevens, Controller2. Tom Richter, VP of Administration/CFO3. Dr. Andrew Sund, PresidentAnticipated Completion Date:? Email sent out to employees 8/15/2022.? Payroll started allocating to federal awards based on time and effort 8/31/2022 payroll.

2022-002 ? Internal Control over Payroll ExpendituresCorrective Action PlanIn response to Audit Finding 2022-002, we will correct this issue by doing the following:1. Both Accounting and HR will continue to sign off on written payroll notices,2. Each pay period when a payroll change notice is received the AccountingDepartment will make sure to verify the information entered into the system matches what is on the written on the payroll notice,3. A monthly review of the Payroll/HR system against all payroll change notices will be conducted.Person(s) Responsible: Tracy BrownTiming for Implementation: April 15thTracy Brown, Fiscal DirectorScott Gray, Executive Director

View of Responsible Officials: As part of the ongoing review of procedures, all wage changes must now be approved in writing by the CEO or her designee for all subordinate staff, and by the Board of Directors for the CEO. All wage changes will be submitted to the payroll processor before any adjustments can be made in the system. Additionally, each payroll is reviewed by a second person to ensure compliance. All supporting documentation of compensation changes will also be placed in the employee's personnel file. Policies and procedures and/or the Financial Procedures Handbook will also be updated to reflect the changes.

Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.

JFT does have all the board minutes on file. However, because we were a small agency, salary rates were not often changed. Additionally, all salary rates and changes were always driven by the ability to obtain the funding needed. Since we were small and there was not always a lot to discuss with the board our board only met twice a year. Therefore, all salary was discussed with the board president, then taken to the board. Unfortunately, there is no formal documentation at this time. As of 2023 our board now meets quarterly. Therefore, the following policy will be included in the fiscal manual: the JFT board of directors will hold a public meeting quarterly. All matters of pay rates and salaries will be approved at the start of each grant cycle. State and county grants will be discussed prior to the July 1 start dates, all federal grants will be discussed prior to October 1. Any changes in salary must be approved by the board and documented in official board minutes. All board minutes will be placed in a locked file in the Fiscal Coordinator’s office.

Starting in 2023 all employees of the Organization will complete formal time sheets. These sheets will be signed by the Administrative Coordinator and by the Fiscal Coordinator and then entered into the system each pay period to rectify this finding.

The Organization will implement control procedures that maintain proper segregation of duties. Allocation of payroll expenditures to federal programs are to be prepared by the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The prepared file and documentation of the review and approval will be retained in a share drive for future access.

Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non‐Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services. Audit Recommendation: We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job‐costing system implemented. Auditee Response: The Organization believes the paychecks and purchases identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made. Corrective Action Plan: UICSL has implemented a new payroll system Paycom to help account for these Labor Allocation and Grant Codes. Employees are automated to each program and there is a designated reporting function allowing us to review what is assigned. UICSL also now has Directors for each division so there is clearly defined approvers and supervisors for each purchase and transaction. Person Responsible: Matt Poss, Director of Finance Operations Timeline: UICSL transitioned to Paycom in back‐half of 2023 and Leadership was designated and assigned for 2023.

Federal Award Findings and Questioned Costs Finding 2022‐002: Inaccurate Staff Timesheet Support Corrective Action: At monthly staff meetings, we will review current contracts, including terminating contracts and new contracts that are beginning. We will inform and train staff regarding the proper recordkeeping of their time allocation on their timesheets. We will also inform and train managers on more thorough oversight of staff time allocation to contracts as part of the timesheet approval process. Name of Contact Person: Heather Hays, Associate Director Proposed Completion Date: Immediately

Item: 2022-004 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities – Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Centers for Disease Control and Prevention Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: The entity’s system of internal controls did detect, or document the rationale for, instances in which the amounts charged to a federal program did not agree to the underlying supporting documentation maintained by the Organization. Condition: The entity’s system of internal controls did detect, or document the rationale for, instances in which the amounts charged to a federal program did not agree to the underlying supporting documentation maintained by the Organization. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2023 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. Billings are reviewed by supervisors, including a review of the underlying supporting documentation, prior to submission of the billing. Additional training and record retention practices will be added and/or enhanced to ensure there is evidence of supervisory review of the underlying supporting documentation. Such review and record retention processes will include documentation of noted discrepancies and rationale for such discrepancies if not corrected.

Item: 2022-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities – Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Centers for Disease Control and Prevention Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR § 200.430 – Compensation – charges to federal programs for salaries and wages should be supported by a system of internal controls which provides reasonable assurance the amounts charged are accurate, allowable and properly allocated. Condition: The entity’s system of internal controls did not retain contemporaneous documentation of supervisory review over payroll allocations charged to the federal programs. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2023 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. Payroll allocations are monitored on a routine basis to ensure they are reasonable and accurate. Additional training and record retention practices will be added and/or enhanced to ensure there is evidence of supervisory review.