Corrective Action Plans

Management Response #2022-005: The time keeping system and process does not currently allow tracking of time based on funded resources. The past practice had been for the finance department manually calculated salary allocations but due to staff turnover in FY2021-22, the process was not consistently followed. Corrective Action Plan: The following action items have been or will be taken: • In 2022, the finance team delineated and expanded positions whose primary responsibility is to monitor and manage all grant activities. • Monthly time and effort reports to include recorded time worked under each grant will be sent to the employee and require employee and supervisor approval. • As of 2022 salary/wages are allocated to federal grants based on actual costs received from payroll. • Finance Management will also create actual to budget reports in accordance with HRSA (Health Resources and Services Administration) guidelines for salaries/wages and hours. The report will be reconciled monthly. • Human Resources department will collaborate with the Grants and Finance teams to ensure grants hours is added as an option within the timekeeping system for accurate recording for FY24. Responsible Party: Tamara Barnes, CFO

Responsible: Thomas Hoover, CFO Corrective Actions: 1) Update Finance policies to document and maintain the documentation of Supervisory review and approval of journal entries charging payroll costs to federal grants; 2) Update Finance policies to review estimates of accrued costs charged to federal grants at calendar/fiscal year end to determine whether true-ups to actual costs are necessary. Completion Date: March 29, 2023 Explanation: 1) Review of allocated payroll costs: Payroll processing and recording of costs charged to federal grants has in practice, consistently involved multiple review and approval steps by at least two employees. Detailed records of these steps are maintained in Finance records for each payroll, including the allocated grant costs. However, Management acknowledges that an additional step be added to capture the documentation of review and approval of the payroll journal entries that allocate payroll costs to federal grants. This step was put in place in 2023 to resolve a recommendation from OJJDP/OCFO. Supervisor review and approval is captured directly in the general ledger system. Finance policies have been updated to codify this additional step as recommended. 2) Procedure for trueing up estimates: Three of sixty transactions tested showed that payroll costs were accrued at year end based on the approved grant budget but were not trued up in the new accounting period based on actual costs. The total variance of the three transactions was $6.20. Finance policies have been updated to include evaluating year-end accruals to determine whether a true-up is necessary in the new period as recommended.

Management acknowledges that it is necessary to more specifically itemize employee time that is applicable to the federal grants and contracts that partially fund broad programs and services and has instituted infrastructure to ensure that this is done and documented correctly in the future. The necessary codes are in place in our payroll system and guidance and leadership of the timesheet process will be provided by all program executives (EVP, VP) to all staff that are impacted, with oversight by the Chief Financial & Operating Officer and Sr. Director of Finance. This is in place as of the date of this corrective action plan.

FINDING # 2022-011No finding in prior yearThe Department of Corrections (DOC) held a meeting on March 22, 2023 with the Supervisors of Education where the importance of reviewing and approving all timesheets was reinforced. Staff were also informed and reminded of progressive discipline for future instances of timesheet approval omissions. DOC also plans to distribute a memorandum to all Supervisors and Assistant Supervisors of Education in an effort to ensure that proper controls are implemented for timely supervisory review and approvals of timesheets as required. Supervisors were also instructed to substantiate via email that timesheet approval, in their absence, will be approved by DOC Administration at their facility.COMPLETION DATE/CONTACT PERSON March 26, 2023Donna Gies - DOC(609) 826-5615Donna.Gies@doc.nj.gov

2022-008 COVID-19-Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: The Office of Budget and Finance in conjunction with the Executive?s office of Government Reform and Strategic Initiative will review all employee files to ensure that an effort attestation exists, or that the employee is properly trained on the importance of effort reporting through a timesheet as a chargeback mechanism.Name(s) of the contact person(s) responsible for corrective action: Elisabeth Sachs and Rebecca LangPlanned completion date for corrective action plan: 7/1/2023

2022-007 COVID-19-Emergency Rental Assistance ? Assistance Listing No. 21.023Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Baltimore County DHCD follows Baltimore County?s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff?s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore is County is discontinuing the use of current payroll system CGI Advantage and will be migrating to Workday system which has more robust features and capabilities to capture time and attendance.Name(s) of the contact person(s) responsible for corrective action: Amir AssadiPlanned completion date for corrective action plan: 7/1/2023

2022-006 CDBG Entitlement Grant Cluster ? Assistance Listing No. 14.218Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: DHCD follows Baltimore County?s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff?s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore County is discontinuing the use of current payroll system CGI Advantage and will be migrating to Workday system which has more robust features and capabilities to capture time and attendance.Name(s) of the contact person(s) responsible for corrective action: Amir AssadiPlanned completion date for corrective action plan: 7/1/2023

2022-009 A/B. Allowable Costs and Cost Principles/Activities Allowed or UnallowedEducation Stabilization Fund CFDA #84.425Material Weakness in Internal Control over Compliance and Immaterial Instance of NoncomplianceFinding Summary: During the course of the engagement, Eide Bailly noted instances of expendituresthat were not COVID related and therefore not allowable under the terms of the grant.Corrective Action Plan: The School will review internal controls surrounding allowable costs andactivities to ensure they are adequate to identify unallowable expenditures.Anticipated Completion Date: June 30, 2023

FINDING 2022-004Contact Person Responsible for Corrective Action: Kristin CharlesContact Phone Number: 765-866-0203Views of the Responsible Official: The School Corporation is in agreement with the Finding.Description of Corrective Action Plan: This should not be an issue moving forward as now write our grant to be used for our Co-Op Bill and do not pay salaries directly. In the future if we plan to pay with Federal Funding, we will require time and effort logs.Anticipated Completion Date: 4/1/2023

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