Corrective Action Plans

Finding 433303 (2022-027)

Significant Deficiency 2022

LA

Subrecipient Monitoring Reporting Special Tests & Provisions

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 20, 2023, regarding a reportable audit finding related to Inadequate Controls over Monitoring of Abortion Claims. LDH appreciates the opportu...

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 20, 2023, regarding a reportable audit finding related to Inadequate Controls over Monitoring of Abortion Claims. LDH appreciates the opportunity to provide this response to your office's findings.Finding: Inadequate Controls over Monitoring of Abortion ClaimsRecommendation: LDH should continue its process to validate self-reported information from the health plans and ensure its process is operating effectively to ensure compliance with federal regulations regarding funding of prohibited abortions claims.LDH Response:LDH concurs with the finding that it did not compare or validate the monthly Managed Care Organization (MCO) self-reported information to ensure the reporting was accurate and complete for the entire fiscal year.LDH developed and proposed an additional review procedure in March 2022 that would validate encounter data to the MCOs self-reported monthly report, but the procedure was not in place prior to the end of state fiscal year 2022. Analysis of encounter data has very significant limitations because the same procedure codes used for an elective abortion are the same procedure codes used for treatments of a fetal death that has already occurred (miscarriage). Therefore, oversight had to be clinically-oriented, which added complexity to the process.The additional review procedure was implemented in July 2022 and reviewed data retrospectively for January 2022 through June 2022.LDH will continue its process to validate the self-reported information from the Managed Care Organizations against encounter data on an ongoing basis and this will be completed for all of Fiscal Year 2023.LDH partially concurs with the finding that the instructions provided to the MCOs concerning how to complete the reports are not detailed and could potentially lead to all five health plans reporting different information. The monthly report includes a definitions tab that includes information on what and how data should be reported. By reviewing reports submitted and encounter data, LDH is able to make determinations on how each MCO is reporting data. However, LDH will review and revise the reporting instructions to include more detail for the MCOs in order to mitigate the potential for misunderstanding by the MCOs.You may contact Tara A. Leblanc, Medicaid Director at (225) 219-7810 or via e-mail at Tara.LeBlanc@la.gov or Brandon Bueche, Medicaid Section Chief at (225) 384-0460 or via email at Brandon.Bueche@la.gov with any questions about this matter.

View Audit 312391

Finding 433302 (2022-025)

Significant Deficiency 2022

State of Louisiana

LA

Internal Control / Segregation of Duties

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated February 6, 2023, regarding a reportable audit finding related to billing controls for behavioral health services. LDH appreciates the opportunity to provi...

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated February 6, 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 implement adequate internal controls to ensure that encounters are coded correctly, which could include edit checks to flag potential improper billings for further review.LDH Response:LDH concurs.As noted in previous audit responses, LDH holds the Managed Care Organizations (MCOs) accountable for implementing necessary claim system edits, as identified in the FY2022 contracts between Bureau of Health Services Financing (BHSF) and each individual MCO. Further, the MCOs must incorporate all National Correct Coding Initiative (NCCI) edits to applicable claims, as well as have the ability to update national standard code sets such as Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (CPT/HCPCS), International Classification of Diseases Codes (ICD-10-CMS), and move to future versions as required by CMS or LDH.In order to meet the above requirements, the MCOs implement a variety of edits that are not dependent on the use of modifiers, including the use of information readily available through interfaces with their provider enrollment and service authorization data. The multiple systems that interface with the MCOs' claims processing systems assist in the validation of claims accuracy based on information such as the provider's qualifications and specialties, the appropriate fee schedule and/or contracted rate for which the provider is eligible, the number and types of services for which the recipient is authorized and the eligibility of the recipient for the service. This is the most effective way for the MCO to adjudicate the claims while reducing administrative burden and preventing provider abrasion. This results in the MCO not being dependent upon modifiers, which may or may not be valid, to process and pay these claims as clean, rather than denying and requiring unnecessary resubmission. The MCOs are also required to perform internal audit reviews to confirm claim edits are functioning properly.System edit checks are a critical function of ensuring the appropriateness of claims payments. However, these edits and functions should not conform to the standard Medicaid SBHS schedule in that this would interfere with the requirement to be adaptable to continuously changing provider specific agreements, out of network agreements, recipient specific agreements; in addition to the accommodation of all of the nuances related to billing and payment methodologies required and/or allowed in contract and as permitted via a variety of Medicaid programs and fee schedules.In reality, claims adjudication systems are incapable of accounting for every variable in a managed care environment that not only encourages, but also requires, flexibility related to alternative payment methodologies. These methodologies include incentivizing providers in rural and other areas with limited access to necessary services; in response to individual client cases in order to ensure that their person-centered medical needs are met, and defining payment rates based on outcomes and performance versus volume.While the managed care entity's independent claims system can accommodate a number of edits, an encounter repository system such as Medicaid's Data Warehouse is further limited as it would be impossible to implement uniform edits across multiple managed care entities which pay varying rates, offer varying services, hold unique provider specific agreements and offer provider specific incentives.Medicaid's Managed Care model places emphasis on efficacy and efficiency, which may not necessarily align with hard coded claims logic across multiple populations, providers and patients' varying medical needs. MCOs may offer additional benefits and rates that are outside the scope and fee of core State Plan benefits and services to individual members on a case-by-case basis, based on medical necessity, cost-effectiveness, the wishes of the member and/or member's family, the potential for improved health status of the member, and functional necessity.In a preliminary review of unique claim numbers provided by the LLA, OBH identified several instances where the SBHS fee schedule was not the source document and where the rate paid did align with the Medicaid rate on file. In reviewing data related to "Bad Modifiers", OBH found more than 5,000 encounters to contain no behavioral health diagnosis. Examples of questionable encounters include those for family practice physician clinics, neurologists, OME, newborn and well child visits, diabetes and hypertension diagnoses. Because Healthy Louisiana Plans pay both physical and behavioral health claims, manually sorting through encounters has shown a wide variety of services are being captured in the review. In combination with just a very small sample of physicians as identified through our partial review, we are questioning over 5,000 encounters totaling over $490,000.Corrective Action PlanLDH will continue to review best practices related to the independent claims processing systems of MCOs, and ensure compliance with and, as needed, development of, contract language to ensure due diligence on their part. Further, LDH has contracted with a third party through the LDH Medicaid office for expansion of the CMS External Quality Review, Protocol 5. While hard edits of encounters against the Medicaid fee schedule are not feasible in Managed Care due to the flexibility MCEs have in reference to payment methodologies for their contracted providers, the EQR will include validation of a representative sample of encounters against the Medicaid fee schedule on file at the time of service delivery, inclusive of modifier utilization .OBH will investigate any discrepancies in order to identify whether those encounters are reflective of an approved alternate payment rate or agreement versus a claim paid outside of the fee schedule, in error. MCEs will be responsible for addressing any erroneous claims inclusive of adjustments or necessary recoupments. Implementation of this protocol began in SFY 2022, with the first report covering the second quarter of the fiscal year that is the basis of this audit. The initial report is due prior to the end of SFY 2023.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.

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Finding 433301 (2022-023)

Material Weakness 2022

State of Louisiana

LA

Special Tests & Provisions Internal Control / Segregation of Duties

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 27, 2023, regarding a reportable audit finding related to Inadequate Controls and Noncompliance over ADP Risk Analysis and System Security R...

Dear Mr. Waguespack:The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 27, 2023, regarding a reportable audit finding related to Inadequate Controls and Noncompliance over ADP Risk Analysis and System Security Review. LDH appreciates the opportunity to provide this response to your office?s findings.Finding: Inadequate Controls and Noncompliance over ADP Risk Analysis and System Security Review.Recommendation: LDH should design and implement procedures to document and support its review of all ADP system security reports.LDH Response: LDH partially concurs with this finding.LDH received and reviewed Service Organization Control (SOC) 1 reports, however there was no written communication between LDH and Magellan regarding the reports. LDH will respond to Magellan SOC 1 reports in writing in the future. LDH Pharmacy adopted the SOC 1 Audit Report procedure for SOC audit review in January 2023 and will utilize it for SFY2023 and subsequent years.LDH did not request a CAP for the requested reports due to the following:? The report indicated controls were not operating effectively however it was determined the controls were not related to Louisiana:o The cover letter and Section V, Other Information Provided by Magellan Rx Management, LLC, note ?Management?s Responses to Exceptions Noted? section Magellan indicated ??is not a part of Magellan Rx?s description of its Rebate Processing system made available to user entities during the period July 1, 2021 to June 30, 2022, hence is not applicable to LDH.?? In addition, Magellan management provided responses, which clarified or rectified the exceptions noted.Corrective Action PlanLDH will respond to Magellan SOC 1 reports in writing in the future. LDH Pharmacy adopted the SOC 1 Audit Report procedure for SOC audit review in January 2023, and will utilize it for SFY2023 and subsequent years.You may contact Tara A. LeBlanc at (225) 219-7810 or via e-mail at Tara.LeBlanc@LA.GOV or Germaine Becks-Moody, Medicaid Program Manager at (225) 342-9479 or via email at germaine.becks-moody@la.gov with any questions about this matter.

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Finding 433300 (2022-032)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles § 200.303

Dear Mr. Waguespack:Please allow this letter to serve as the official response for both the Management Letter and the Single Audit Report in reference to the finding concerning Control Weakness Relating to Foster Care Billings.The Office of Juvenile Justice (OJJ) does concur with the finding. The ag...

Dear Mr. Waguespack:Please allow this letter to serve as the official response for both the Management Letter and the Single Audit Report in reference to the finding concerning Control Weakness Relating to Foster Care Billings.The Office of Juvenile Justice (OJJ) does concur with the finding. The agency and LA Department of Public Safety (DPS), Office of Management and Finance, Financial Services, which is responsible for performing the back office functions for OJJ, has a responsibility for ensuring that the Foster Care administrative invoices are properly reviewed prior to submission to the Department of Children and Family Services (DCFS) for reimbursement. Inadequate review of the invoice submission for quarter ending December 2021 resulted in an overpayment of $128,236.00 from DCFS made to OJJ.Effectively immediately, an additional level of review and approval of the Foster Care administrative invoices will be added to the process. Samantha Dunbar, DPS Staff Accountant, will continue to prepare the invoices, and submit the invoice and supporting documentation to Wanda Armwood, DPS lead Staff Accountant for the first level review and approval. Once the Lead Accountant approves, the invoices and documentation will be forwarded to A'shli Oliver, DPS Accounting Manager, for the second level review and approval. Once the second level approval has been completed, the DPS Accounting Manager will submit the invoices and documentation to OJJ staff for final review and approval. Undersecretary, Jason Starnes will provide the final approval of the invoices after Karli Pullard, Program Manager at OJJ, and Cassandra Washington, Deputy Undersecretary at OJJ, have reviewed and approved the invoices submitted by DPS.

View Audit 312391 Questioned Costs: $1

Finding 433298 (2022-019)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Subrecipient Monitoring § 200.332

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has reviewed the finding ?Control Weakness Relating to Foster Care Subrecipient Monitoring.? The finding states DCFS did not adequately review subrecipient Foster Care Invoices submitted by the Office of Juvenile Justice (OJJ)...

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has reviewed the finding ?Control Weakness Relating to Foster Care Subrecipient Monitoring.? The finding states DCFS did not adequately review subrecipient Foster Care Invoices submitted by the Office of Juvenile Justice (OJJ) for reimbursement of administrative expenditures to ensure billings were accurately calculated. DCFS concurs with the finding.DCFS will establish a secondary level of review to ensure accuracy of OJJ administrative invoices prior to reimbursement. The Child Welfare Consultant will review OJJ?s IVE Administrative Expenditure Invoice for accuracy. Upon verification of an accurate OJJ invoice, the Federal Programs Manager will conduct a secondary level review to confirm accurate calculation of administrative expenditures.If discrepancies are noted, the Consultant will contact OJJ for clarification and request corrections, if necessary. OJJ will be required to submit a corrected invoice. Upon receipt of the corrected invoice, the Consultant will conduct a review of the invoice to ensure accuracy. The Consultant will submit the invoice to the Federal Programs Manager for a secondary level review. This secondary level reviewer will ensure no additional issues exist and will confirm the accuracy of the calculations for administrative expenditures.Secondary level reviews of OJJ administrative expenditure invoices will begin immediately and DCFS is working with OJJ to recover the overpayment through deduction from the next FY22 Quarterly invoice submitted by OJJ.If you have any additional questions, please reach out Sharla Thomas, Child Welfare Manager 2, at Sharla.Thomas.DCFS@la.gov.

View Audit 312391 Questioned Costs: $1

Finding 433294 (2022-021)

Significant Deficiency 2022

State of Louisiana

LA

Subrecipient Monitoring Reporting

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has received the finding titled ?Noncompliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act.?The finding noted that DCFS did not report subawards in compliance with the Federal Fundin...

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has received the finding titled ?Noncompliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act.?The finding noted that DCFS did not report subawards in compliance with the Federal Funding Accountability and Transparency Act (FFATA) in the FFATA Subaward Reporting System (FSRS) during fiscal year 2022 for the Foster Care Title IV-E and the Temporary Assistance for Needy Families programs. We concur with the finding.DCFS is presently developing policies and procedures to ensure accurate and timely reporting of data required by the FFATA in FSRS and is working to collect the required information from subrecipients to begin reporting. We will implement and train staff on policies and procedures regarding FFATA reporting requirements and begin reporting required data in FSRS on an ongoing basis in accordance with FFATA required timeframes by March 31, 2023.The contact person for Foster Care Title IV-E reporting is Tina Joseph, Program Manager, who may be reached at 225-342-4152 or tina.josheph.dcfs@la.gov. The contact persons for TANF reporting are Julie Starns, Program Manager, who may be reached at 225-342-0495 or julie.starns.dcfs@la.gov, and Robert Williams, Program Manager, who may be reached at 225-342- 4791 or robert.williams.dcfs@la.gov.

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Finding 433293 (2022-020)

Significant Deficiency 2022

State of Louisiana

LA

Special Tests & Provisions Internal Control / Segregation of Duties

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has received the finding titled "Noncompliance and Control Weakness relating to the Temporary Assistance for Needy Families (TANF) Work Verification Plan."The finding states the Department of Children and Family Services (DCFS...

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has received the finding titled "Noncompliance and Control Weakness relating to the Temporary Assistance for Needy Families (TANF) Work Verification Plan."The finding states the Department of Children and Family Services (DCFS) did not ensure that all work activity supporting documentation for cash assistance recipients was accurate and maintained for hours worked under the Temporary Assistance for Needy Families (TANF) program. DCFS concurs with the finding and will ensure proper documentation through training and case reviews.In alignment with the Department's continued improvements, we have restructured the Department to bring TANF and Workforce Development under the same umbrella to provide training and additional oversight of the STEP program. The TANF consultants will review the Strategies to Empower People (STEP) cases monthly to ensure work activities are properly documented in the Louisiana Integrated Technology for Eligibility (LITE) system and to improve the outcomes of TANF participants. This process is ongoing and began this month.The Temporary Assistance for Needy Families (TANF) grants increased in January 2022. As a result, the number of participants in the STEP program doubled. The STEP coaches were working forty (40) cases per month, and this jumped to one hundred (100) cases after the grant increase. The Louisiana Department of Children & Family Services has been working expeditiously to bring additional staff on board and meet the demands of this vulnerable population. Training has been revamped with a laser focus on documentation, policy, systems, and the Goal4 It! Case Management model. The Goal4 It! model invokes core self-regulation skills such as planning, prioritization, and metacognition which creates opportunities for the STEP participant to practice this approach with their personal and employment-related goals. Statewide training will be completed on March 3, 2023.In addition, we are entering new contractual agreements with organizations throughout Louisiana. The STEP participants will have access to a variety of employers, training providers, and work activities. More recently, we have contracted with South Louisiana Community College and the Prosperity Center at United Way of Southeast Louisiana.Technological systems improvements are underway in the TANF/STEP programs to allow for more effective reporting and data analysis. DCFS continues to work with vendors to align the Louisiana Integrated Technology for Eligibility (LITE) system with the Goal4It! Model. We look forward to the new enhancements which will give the STEP coaches the opportunity to fully document all case actions including good cause determinations. Integration of the TuaPath system with LITE is also underway. TuaPath is a case management tool accessible to both participants and coaches. It provides greater accountability for participants to set their own goals, enter participation hours, and upload documentation. The enhancement of the LITE system and the implementation of Tuapath will assist DCFS in reporting work activities. The LITE and TuaPath integration is slated for completion at the end of July 2023.If you have any additional questions, please reach out to Deputy Assistant Secretary Lorrie Briggs, who oversees TANF and the associated work program STEP. You can reach her at (337) 344-9676 or Lorrie.Briggs.DCFS@la.gov.

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Finding 433289 (2022-018)

Significant Deficiency 2022

State of Louisiana

LA

Subrecipient Monitoring § 200.332

Mr. Waguespack,Please accept this response to the audit conducted by your office on the Acadiana Area Human Services District (AAHSD). There were two findings listed: 1) Inadequate Controls over Sub - Recipient Agreements; 2) Untimely Billing of Patient Services.Please find the response for each und...

Mr. Waguespack,Please accept this response to the audit conducted by your office on the Acadiana Area Human Services District (AAHSD). There were two findings listed: 1) Inadequate Controls over Sub - Recipient Agreements; 2) Untimely Billing of Patient Services.Please find the response for each under separate letter attached.We appreciate the feedback and comments from your team and will use this information to improve our systems and processes.Finding:Inadequate Controls over Subrecipient AgreementsComment:We concur with this finding. AAHSD works closely with the Louisiana Department of Health (LDH) regarding interagency transfers (IAT) and other grant funding, including TANF and Block Grant funds. Much of the information required to demonstrate compliance with this element is maintained by LDH and was not always accessible to us in a timely manner. Additionally, we have worked with LDH to revise the documentation regarding risk assessment for the subrecipients.Corrective Action:? AAHSD will develop and implement an appropriate checklist of required information regarding:o identification of Federal award informationo a risk assessment of the subrecipients' non-compliance? AAHSD has revised our contract template to include the necessary information regarding audits of subrecipient organizations? AAHSD will request all necessary information from subrecipient organizations at the initiation of the contracting process rather than waiting on notification from LDHPerson(s) Responsible:The Executive Director is ultimately responsible for ensuring all corrective action. Specific duties may be delegated to other senior managers, specifically: the Chief Financial Officer; the Director of Behavioral Health; and the Corporate Compliance/Accreditation Officer.Timeframe:All action points implemented within 90 calendar days of receiving the final audit report.

View Audit 312391

Finding 433287 (2022-004)

Material Weakness 2022

State of Louisiana

LA

Allowable Costs / Cost Principles § 200.430

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 t...

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.

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Finding 433282 (2022-016)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles

Dear Mr. Waguespack:Listed below is the University's response to the finding regarding Control Weaknesses over Higher Education Emergency Relief Funds RequirementsFINDING: Control Weaknesses over Higher Education Emergency Relief Funds RequirementsRESPONSE: Southern University - Baton Rouge (SUBR) c...

Dear Mr. Waguespack:Listed below is the University's response to the finding regarding Control Weaknesses over Higher Education Emergency Relief Funds RequirementsFINDING: Control Weaknesses over Higher Education Emergency Relief Funds RequirementsRESPONSE: Southern University - Baton Rouge (SUBR) concurs in part with the above noted finding.The University does not concur that this is the second consecutive year to have the same reported weaknesses. The University implemented corrective action in the prior year. Of the four errors included in the prior year audit finding, the University corrected three of the errors. The error related to loss revenue was corrected during the prior year audit. The below error was not a part of the condition of the prior year audit finding. In addition, the timely implementation of recommendations demonstrates the University's management desire to be accountable for, and a willingness to improve their operations.The University does concur that during the current year a formula error did result in a calculation of loss revenue using the four (4) year combined average instead of the 5 (five) year combined average revenue as baseline revenue. This resulted in an overdraw of funds in fiscal year 2022 by $1.9 million. However, the University had a $2.5 million under draw from fiscal year 2021 to offset this, resulting in a net under draw of approximately $600,000.The University will continue to review the USDOE website and attend webinars for guidance related to HEERF reporting requirements. Management will continue to monitor the concerns noted in this finding.Mr. Flandus McClinton, Vice President for Finance and Business Affairs, is responsible for implementing and monitoring corrective actions. The projected deadline to finalize the review of the concern brought to the University's attention with this audit finding is June 30, 2023.If you have any questions or require additional information, please contact Mr. Flandus McClinton, Jr. at 225- 771.6278.

View Audit 312391 Questioned Costs: $1

Finding 433281 (2022-015)

Significant Deficiency 2022

State of Louisiana

LA

Reporting Internal Control / Segregation of Duties

Dear Mr. Waguespack:Listed below is the University's response to the finding regarding Control Weakness over Higher Education Emergency Relief Funds ReportingFINDING: Control Weakness over Higher Education Emergency Relief Funds ReportingRESPONSE: Southern University - Baton Rouge (SUBR) concurs in ...

Dear Mr. Waguespack:Listed below is the University's response to the finding regarding Control Weakness over Higher Education Emergency Relief Funds ReportingFINDING: Control Weakness over Higher Education Emergency Relief Funds ReportingRESPONSE: Southern University - Baton Rouge (SUBR) concurs in part with the above noted finding.The University does not concur that this is the third consecutive year to have the same reported weaknesses. The University did implement corrective action for the prior year audit finding. Of the three bullets included in the prior year audit finding, the University did not concur with one of the bullets, based on its interpretation of the United States Department of Education (USDOE) reporting requirements, and the two remaining bullets, wherein the University did concur, were corrected and are not a part of the condition of this finding. In addition, the timely implementation of recommendations demonstrates the University's management desire to be accountable for, and a willingness to improve, their operations.The University concurs with the current year's weaknesses wherein there was an understatement of expenditures on the Higher Education Emergency Relief Funds (HEERF) on two of the quarterly reports in the amount of $1,216,444 and on the annual report in the amount of $1,674,977. Due to a change in the USDOE reporting requirements, which specifically changed the quarterly reporting from cumulative to not cumulative, the University revisited the quarterly reports that were posted on the website to make the requested revisions and inadvertently understated the expenditures.At the time these two quarterly reports were prepared and posted, the USDOE had a requirement, which has since been revised, that the reports agree to the expenditures recorded, not the drawdown amounts. There is a USDOE requirement that all quarterly reports are posted by the 10th day following the end of the quarter, which results in the University preparing the reports immediately after the end of the quarter to meet the deadline. Therefore, generating a list of all transactions after the entire year has closed, to include the accrual period and comparing it to the transactions that were posted for the quarter to meet the deadline, resulted in an understatement of expenditures on the reports. Also, the University concurs that the age category was misclassified for 145 students (1.4% error rate).The USDOE allowed all reporting entities to revise the HEERF Annual 2021 data when entering the 2022 data into the HEERF portal. The USDOE has confirmed that the University may charge its HEERF grant awards for expenditures from March 13, 2020 through the performance period of the HEERF grants.The University will continue to review the USDOE website and attend webinars for guidance related to HEERF reporting requirements. Management will continue to monitor the concerns noted in this finding.The campus personnel responsible for implementing and monitoring corrective actions are Mr. Flandus McClinton, Vice President for Finance and Business Affairs and Mr. Terry Hall, Vice Chancellor for Financial Affairs. The projected deadline to finalize the review of the concerns brought to the University's attention with this audit finding is June 30, 2023.If you have any questions or require additional information, please contact Mr. Flandus McClinton at 225.771.6278.

View Audit 312391

Finding 433279 (2022-013)

Significant Deficiency 2022

State of Louisiana

LA

Reporting

Dear Mr. Waguespack,Baton Rouge Community College concurs with the finding Higher Education Emergency Relief Fund Reporting Weakness.For the errors identified in the finding the College has completed the following corrective actions:? The correct quarterly report for the Institutional and Minority S...

Dear Mr. Waguespack,Baton Rouge Community College concurs with the finding Higher Education Emergency Relief Fund Reporting Weakness.For the errors identified in the finding the College has completed the following corrective actions:? The correct quarterly report for the Institutional and Minority Serving Institution (MSI) portions for the quarter ending September 30,2021 is now posted.? The Quarterly Public Reporting for the Student Aid Portion for the quarters ending September 30, 2021, and December 31, 2021 were publicly posted in January 2022. Since then the College has publicly posted all student quarterly report by the established deadlines.? The Spring 21 student disbursements were double counted in the underlying data which led to the inaccurate reporting of the amount and number students who received HEERF emergency financial aid grants. The data in the annual report for the calendar year ending December 31, 2021 has been updated to accurately report the number of students that received HEERF emergency financial aid grants and the amounts disbursed directly to student as emergency financial aid grants. The updated annual report has been submitted to the United States Department of Education.The College's corrective action plan will include reviews of the reports that are completed by the Office of Accounting and Finance Staff to ensure the reports are posted timely and accurately. The correction action plan will be fully implemented by June 30th, 2023. The Vice Chancellor of Finance and Administration, Corlin LeBlanc will be responsible for ensuring the corrective actions are completed and the College complies with the applicable HEERF reporting requirements.

View Audit 312391

Finding 433276 (2022-014)

Significant Deficiency 2022

State of Louisiana

LA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Dear Mr. Waguespack,Please accept this letter as the official response from the Louisiana Department of Education (LDOE) to the audit finding entitled Non-Compliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA) for the fiscal year ending June 30, 20...

Dear Mr. Waguespack,Please accept this letter as the official response from the Louisiana Department of Education (LDOE) to the audit finding entitled Non-Compliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA) for the fiscal year ending June 30, 2022.Recommendation:DOE should continue to strengthen internal controls to ensure that appropriate personnel are aware of the federal programs that are subject to FFATA reporting and assign appropriate personnel to complete the FFATA reporting in accordance with federal requirements.LDOE Response:In order to strengthen internal controls over FFATA reporting to address the recommendation, the LDOE has implemented procedures to identify appropriate personnel as responsible for the preparation and submission of FFATA reporting in addition to providing training to the responsible personnel on federal regulations regarding required reporting. The agency?s third-party electronic grants management system vendor has provided the reports for FFATA Reporting that ensures accurate data submission in accordance with the federal requirements, therefore the LDOE concurs with the finding. The LDOE plans to have these corrective actions in place no later than September 30, 2023.Contributing Factor:As part of the formal response, LDOE would like to identify the Federal Subaward Reporting System (FSRS) as a contributing factor in the resolution process for FFATA reporting. While LDOE is and will continue to work through the process of submission/correction to FFATA reporting, please note that timely/accurate submission is to some extent dependent on the submission process as designed by the FSRS. LDOE has and continues to encounter technical issues with the FSRS site where these reports are uploaded. To resolve the issues, the staff must submit FSRS Helpdesk tickets whereas the timely resolution of the tickets are a vital component of the corrective action protocols. Upon request, LDOE provides our program contact at the US Department of Education (ED) information regarding its outstanding helpdesk tickets and their status for resolution. The agency?s team is maintaining a record regarding the ticket submissions and their resolution status to ensure all FFATA reports are submitted accurately and timely.The Department takes seriously the reporting requirements for FFATA and is dedicated to ensuring the reporting is accurate and timely. Further questions concerning this response may be directed to Mr. Bernell Cook, by telephone at 225-342-1050 or via email at bernell.cook@la.gov.

View Audit 312391

Finding 433275 (2022-017)

Significant Deficiency 2022

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles § 200.430

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 ...

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.

View Audit 312391 Questioned Costs: $1

Finding 433268 (2022-011)

Material Weakness 2022

State of Louisiana

LA

Subrecipient Monitoring § 200.332

Dear Mr. Waguespack,The Louisiana Workforce Commission (LWC) respectfully submits its response to the Single Audit Report finding of Inadequate Controls Over and Noncompliance with Subrecipient Monitoring Requirements.First and foremost, it is important to note that the Compliance and Monitoring Uni...

Dear Mr. Waguespack,The Louisiana Workforce Commission (LWC) respectfully submits its response to the Single Audit Report finding of Inadequate Controls Over and Noncompliance with Subrecipient Monitoring Requirements.First and foremost, it is important to note that the Compliance and Monitoring Unit of LWC has been working very diligently to comply with the requirements of the Workforce Innovation and Opportunity Act (WIOA) of annual monitoring reviews of subrecipients. LWC recognizes the importance of monitoring our subrecipients and in doing so performs their due diligence to ensure that compliance with all legal requirements within WIOA are met. Enormous strides are being made towards improving and sustaining the great work that has already been done. We will continue our efforts to ensure that we remain on track in accomplishing full compliance with subrecipient monitoring at the close of the current fiscal year.Should you have any questions or need additional information, please feel free to contact my office at (225) 342-3001.? Two monitoring reports were not issued timely by LWC. The monitoring reports were issued 74 and 75 days after the completion of the monitoring review. LWC?s policy requires monitoring review reports to be issued 60 days after the completion of the monitoring review.? LWC concurs with this portion of the finding that 2 out of the 15 monitoring reports were issued more than 60 days after the conclusion of the monitoring review. We find it important to note that the late issuance of the 2 monitoring reports is a direct result of the many challenges LWC faced during the monitoring cycle. As a result of these challenges, LWC undertook a review of its internal policy and has made revisions to the policy with regard to, among other things, the timeliness of the issuance of monitoring reports.? For four monitoring reports, close out letters were issued 145 to 191 days after monitoring report issuance. For six monitoring reports, close out letters were not issued as of January 2023 while the monitoring reports for these reviews were issued over 200 days prior. The monitoring reports include findings with possible questioned cost totaling $3.1 million. LWC policy does not specifically address timeliness requirements for closeout letters.? LWC concurs in part with this finding concluding that four close out letters were issued 145 to 191 days after monitoring report issuance and that six close out letters were not issued as of January 2023 while the monitoring reports for these reviews were issued over 200 days prior. However, LWC does not concur with the overarching conclusion that its policy does not specifically address timeliness requirements for closeout letters.A closeout letter is not generated to a subrecipient unless all findings identified in the monitoring report have been resolved. When findings are identified in the monitoring report, subrecipients are given the opportunity to clear those findings by submitting a Corrective Action Plan (CAP). A CAP is the subrecipient?s opportunity to address the cause of the findings and provide LWC with a well thought-out plan not only address the cause of the finding but to implement steps to prevent findings of that nature in the future. Until the CAP is submitted, all steps executed, and a determination that the finding has been resolved, a closeout letter will not be issued.If a subrecipient submits a CAP, LWC periodically reviews the CAP with the subrecipient to determine whether sufficient steps are being taken toward resolution of the finding(s). If at some point, it is determined that resolution is not attainable, an initial determination is then issued.For the time period covering the Single Audit, LWC?s policy provided for the following:? Within 45 days of issuance of the monitoring report, the subrecipient must submit a corrective action plan for all findings listed in the monitoring report.? Within 30 days of receiving the corrective action plan from the subrecipient, LWC would notify the subrecipient of acceptance or rejection of the corrective action plan.The next step in the process, as articulated in LWC?s policy is the initial determination.? Three subrecipients had findings on the monitoring reports stemming from a lack of documentation supporting the subrecipients? drawdowns of WIOA funds and drawdowns of federal funds could not be reconciled by LWC to the subrecipients accounting records. The monitoring reports noted potential questioned cost associated with these drawdowns. These reviews are included in the six monitoring reports not issued as of January 2023, noted in the bullet above. Timely resolution would allow LWC to quickly address any compliance issues at the subrecipients? level. According to LWC, it is working with the subrecipients to reconcile the federal funds drawdowns and close out the reports.? LWC received unorganized data from the subrecipients. In response to LWC?s request for financial documentation such as general ledgers, balance sheets, expenditure reporting, invoices, etc., subrecipients basically did a data dump. There was no legend or other identifying information associated with the data that was submitted and opening each unidentified file, reviewing it and trying to identify it with thousands of transaction for 15 subrecipients proved tedious, time-consuming and confusing. In an effort to stick as closely as possible to very tight timelines, LWC issued a finding within the monitoring report anticipating that the finding would compel the subrecipients to work with LWC to resolve the differences. As a result of issuing these findings the subrecipients developed corrective action plans to resolve the differences in the drawdown reconciliations. LWC created internal control documents to assist in the organization of material received from the subrecipients. The documents will be utilized when performing the review of the financial portions of the monitoring.Documents that were created include:REQUEST FOR DOCUMENTS - The ?Request for Documents? is a document that details for the subrecipient how documents are to be submitted and labeled. Attached is a copy of the Request for Documents and a detail of the new layout of how the documents are to be uploaded. Portions of the corrective action plan were omitted due to character limitations; See Corrective Action Plan for attachment.INTERNAL CONTROL QUESTIONNAIRE - The ?Internal Control Questionnaire? is a series of queries that helps LWC understand the structure and workflow of the subrecipient. Attached is a copy of the Internal Control Questionnaire. Portions of the corrective action plan were omitted due to character limitations; See Corrective Action Plan for attachment.The new format has significantly reduced the amount of time to complete the financial monitoring of the subrecipient.

View Audit 312391

Finding 433266 (2022-012)

Material Weakness 2022

State of Louisiana

LA

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Dear Mr. Waguespack:The Louisiana Workforce Commission (LWC) respectfully submits its response to the finding Inadequate Controls and Noncompliance with Unemployment Insurance Benefits Requirements, included in the Single Audit Report.The LWC vehemently disagrees with the LLA?s interpretation of fed...

Dear Mr. Waguespack:The Louisiana Workforce Commission (LWC) respectfully submits its response to the finding Inadequate Controls and Noncompliance with Unemployment Insurance Benefits Requirements, included in the Single Audit Report.The LWC vehemently disagrees with the LLA?s interpretation of federal ?wage documentation? and identity verification requirements. Assuming arguendo the LLA actually meant ?proof of employment? rather than ?wage documentation?, any determination or finding of a failure to provide proof of employment is premature absent a request to provide such proof and absent USDOL disposition of the State?s blanket waiver request. As stated in the report, LWC issued more than $681 million in benefit payments to more than 260,000 claimants during Fiscal Year 2022. The questioned costs of $30,704, however, account for less than 0.005 percent of total benefits paid.It should be noted that all of the purported ?errors? identified in the report occurred under the hastily assembled Pandemic Unemployment Assistance (PUA) program. The implementing legislation (CARES ACT) and initial USDOL guidance for implementation of the PUA program expressly prohibited states from verifying employment and wages, establishing PUA as a self- attestation program. States were inundated with claims that, when taken at face value, appeared to qualify for benefits. It was only after widespread fraudulent activity and rampant abuse of the self-attestation legal requirement that Congress later implemented identification, employment, and wage verification requirements to be completed either during the application process or retroactively. The program requirements were ever-evolving and amended to address situations and deficiencies that all states encountered. Many states are still working to implement this retroactive guidance provided by USDOL.Although our State ended pandemic programs in July 2021, we continue to work through a substantial backlog of pandemic cases, a backlog that is a direct result of the PUA program?s initial lax requirements. What is more, in August of 2021, less than one month after the pandemic programs ended, the state faced its sixth declared disaster in a two-year period, and the LWC was immediately tasked with administering Disaster Unemployment Assistance for yet another major disaster. The LWC responded to the Pandemic and the multiple disasters that impacted the state as effectively as possible. Our Agency will continue to work diligently to resolve the issues noted in the report and to investigate claims to determine proper eligibility.Should you have any questions or need additional information, please feel free to contact my office at 225-342-3001.Inadequate Internal Controls and Noncompliance with Unemployment Insurance Benefit RequirementsThe Louisiana Workforce Commission (LWC) concurs in part. As stated in our response to the same finding last year, it was nearly impossible to implement adequate internal controls and ensure full compliance with the pandemic programs given little time, insufficient guidance, and inadequate resources to implement not only the initial requirements, but later burdensome retroactive requirements all while managing a record-breaking surge in claims volume.Wage Documentation RequirementsIn all cases cited in this report, the ?wage documentation? the auditor was expecting to see is what is referred to as ?proof of employment.? This finding refers to a retroactive requirement that was put in place with the Continued Assistance Act (CAA) and requires the Agency to provide notice to individuals, who filed for PUA before enactment of this requirement, to provide proof of employment within 90 days ?all after previously notifying them that proof of employment was not a requirement of the program. Failure on the part of the individual to provide proof of employment would result in a retroactive disqualification back to December 27, 2020, thus causing a substantial overpayment. The 90-day timeframe does not commence until an official request is transmitted to the individual.The documentation was not on file for the cases in question because the LWC has not yet requested this information from individuals subject to the 90-day proof of employment requirement. Not only was there a ?unique confluence of circumstances? that prevented the LWC from sending out these notices in a timely fashion, but we strongly believe that any overpayments resulting from a claimant?s non-compliance with this requirement is through no fault of their own. To that end, last year, the LWC requested a blanket waiver of overpayments resulting from implementation of this requirement. USDOL ETA?s response to this request will dictate how we proceed with implementation of this requirement. The blanket waiver allowance would only slightly minimize the burden and confusion that implementation of this retroactive requirement causes.Missing IdentificationThe LWC agreed to disagree with the LLA?s interpretation of the identity verification requirements set forth in the CAA. Unemployment Insurance Program Letter 16-20, change 4 provided the following guidance:Requirement to Verify Identity. Section 242 of the Continued Assistance Act requires that states must include procedures for identity verification or validation for timely payment, to the extent reasonable and practicable, by January 26, 2021 (30 days after the enactment of the Continued Assistance Act) to ensure that they have an adequate system for administering the PUA program. Refer to section C.3. of Attachment I to this UIPL for additional details. [Emphasis supplied.]Section C.3:Verification of Identity (Section 242(a) of the Continued Assistance Act) (new). Section 242(a) of Continued Assistance Act modifies Section 2102(f)(1) of the CARES Act. For states to have an adequate system for administering the PUA program, states must include procedures for ?identity verification or validation and for timely payment, to the extent reasonable and practicable? by January 26, 2021, which is 30 days after December 27, 2020 (enactment of the Continued Assistance Act). States that previously verified an individual?s identity on a UC, EB, or PEUC claim within the last 12 months are not required to re-verify identity on the PUA claim, though the Department encourages the state to take additional measures if the identity is questioned. Individuals filing new PUA initial claims that have not been through the state?s identity verification process must have their identities verified to be eligible. The Department strongly encourages states to use the Identity Verification (IDV) solution offered by the UI Integrity Center as part of its Integrity Data Hub (IDH) as one method to meet this requirement. This IDV solution offers states advanced fraud risk scoring to I-13 maximize front-end ID verification, aiding states in assessing whether an individual is using a false, stolen, or synthetic ID. It is available to states at no cost and is a secure, robust, centralized, multi-state data system that allows participating state UI agencies to submit claims for cross matching and analysis to support the prevention and detection of improper payments, fraud, and ID theft. There is also a range of other tools on the market that states may consider to satisfy this requirement for identity verification. States are also strongly encouraged to explore implementation of complementary and rigorous forms of identity verification solutions. The Department will provide states with additional administrative funding to support state costs to implement PUA identity verification processes and solutions and to continue work to address fraud in both the PUA and PEUC programs.[Emphasis supplied.]In the above guidance, we see two requirements (i.e., ?states must?) for our system to be considered ?adequate? for the purpose of administering the PUA program. First, we must have identity verification or validation procedures in place, to the extent reasonable and practicable, by January 26, 2021. In order to thwart the surge of fraudulent claim activity, the LWC implemented identity verification procedures in November 2020 and going forward for all new claims filed, including all new PUA claims. Additionally, we implemented identity verification procedures for anyone whose claim was flagged for suspicious indicators that called into question the individual?s identity. These procedural safeguards were in place even before November 2020. Second, we must verify identities for all individuals filing new PUA initial claims.In the four cases cited in this report, all were PUA initial claims filed long before the CAA identity verification requirements were enacted, and none had been flagged for staff?s review based on suspicious indicators that called the claimant?s identity into question. It would not have been ?reasonable or practicable? for us to verify identities on every single PUA claim filed since the beginning of the Pandemic. The workload the new identity verification requirement created was already more than existing staff and system resources could timely handle.Child Support DeductionsThe child support payments were not properly withheld in the case cited on the report due to a one-off staff training issue. Staff closed the child support work item with no action taken in error, believing the claim was monetarily ineligible. The staff person overlooked that there was an existing PUA claim on file.Contact Person: Margaret MabileCorrective Action Plan: The LWC will continue to work through the pandemic backlog and address issues as they arise.Anticipate Completion Date: Ongoing

View Audit 312391

Finding 433263 (2022-010)

None 2022

State of Louisiana

LA

Questioned Costs Eligibility Subrecipient Monitoring

Dear Mr. Waguespack:The Division of Administration, Louisiana Office of Community Development (LOCD) is submitting the following in response to the audit finding titled "Restore Louisiana Homeowner Assistance Program Awards Identified for Grant Recovery."LOCD acknowledges the LLA finding of "Restore...

Dear Mr. Waguespack:The Division of Administration, Louisiana Office of Community Development (LOCD) is submitting the following in response to the audit finding titled "Restore Louisiana Homeowner Assistance Program Awards Identified for Grant Recovery."LOCD acknowledges the LLA finding of "Restore Homeowner awards identified for Grant Recovery. " In response to the 2016 Floods, the LOCD created the Restore Louisiana Homeowner Assistance Program (HAP). Grant recapture procedures were established from the beginning of the program and have been implemented timely. It is impossible to administer a disaster recovery program that will not have certain files requiring grant recapture during the life of the program. The Restore Program requires a duplication of benefits check on all files prior to grant execution. For example, it is always possible an applicant may receive additional funding, e.g., insurance proceeds that are deemed duplicative by law. The Restore Program has controls in place to capture these amounts in the grants management system, subrogation agreements executed with each applicant, and recapture procedures to recover the funds. From the very beginning, the Restore Program was created to minimize the potential of applicants' ending up in recapture. As a result, the state has issued over $670 million to 17,262 homeowners of which 80, or 0.46% have been placed in recapture. As the Restore Homeowner Program comes to a close, LOCD does not anticipate further files requiring recapture of funds.LOCD agrees with the observation of 8 files with a potential grant recapture as a necessary ongoing activity for the Program. LOCD will continue to follow the established recapture procedures for these grant awards to ensure ultimate compliance, however, this is not a corrective action, but rather the continued implementation of program protocols.The contact person responsible for these ongoing compliance activities is Ginger Moses, OCD Chief Operating Officer. The anticipated completion date for activities addressing this finding will coincide with the closing of the Restore Louisiana program.If you have questions or require additional information, please feel free to contact me.

View Audit 312391 Questioned Costs: $1

Finding 433262 (2022-009)

None 2022

State of Louisiana

LA

Questioned Costs Eligibility Subrecipient Monitoring

Dear Mr. Waguespack:The Division of Administration, Louisiana Office of Community Development (OCD) submits the following in response to the audit finding titled "Inadequate Recovery of Small Rental Property Program Loans."The Small Rental Property Program (SRPP) has two tiers of compliance obligati...

Dear Mr. Waguespack:The Division of Administration, Louisiana Office of Community Development (OCD) submits the following in response to the audit finding titled "Inadequate Recovery of Small Rental Property Program Loans."The Small Rental Property Program (SRPP) has two tiers of compliance obligations. The federal compliance requirements are for the CDBG funds issued to a borrower to meet a National Objective and be expended on an Eligible Activity. On top of the federal requirements, the State has its own program requirements. Upon the initial placement of an eligible tenant in a habitable unit at a restricted rent amount, the U.S. Department of Housing and Urban Development (HUD) requirements have been satisfied. Most of the matters made the subject of your report deal with the borrower's non-compliance with the State's program rules, not the HUD requirements.OCD has allocated approximately $649 million to the SRPP program to fund approximately 4,500 applicants and we maintain an ongoing monitoring process to promote compliance and continued availability of affordable housing. Consistent with the program's mission of preserving and expanding much needed affordable housing, OCD's primary focus for the SRPP is to assist property owners in achieving and maintaining compliance, i.e., creating and continuing affordable housing opportunities, as opposed to foreclosure and/or recapture of funds, and are, therefore, not subject to recapture by HUD.In summary, as of June 30, 2022, the LLA reports that 1,156 applicant files have been identified as noncompliant. Of these, 163 files have been determined to be uncollectible, leaving 993 files that are actively being addressed. OCD's compliance and repayment efforts relating to the state imposed continuing requirements of the program are ongoing. See corrective action plan for footnote. The optimal outcome of these efforts is the continued availability of affordable housing through compliance.In June 2016, OCD, working with the Louisiana Housing Corporation (LHC) and HUD, identified 397 SRPP borrowers that did not meet a National Objective. Immediately thereafter, OCD's Legal Section and LHC program staff began communicating with non-compliant borrowers and evaluating proposed workouts. OCD sent default letters to and initiated recapture efforts on all borrowers. Each file is processed with a goal of either achieving compliance, securing repayment, or identifying another viable workout plan. As of June 30, 2022, of the 397 files identified, 76 borrowers have become compliant, 14 have either partially or fully repaid their loans, 18 borrowers have transferred their housing obligations to other compliant properties and 28 have been determined uncollectable for various reasons. As noted in the audit, OCD continues to seek technical assistance regarding the enforcement of mortgages through the judicial foreclosure/public auction process.In conclusion, OCD will continue the efforts to recover those loans determined to be ineligible in accordance with policies and procedures that are acceptable to HUD. Concurrently, OCD will also continue to assist rental property owners to become compliant and to resolve any program compliance issues, thus increasing available affordable rental housing and reducing or eliminating the need to recapture funds from rental property owners, where appropriate.The contact person responsible for the corrective action is Ginger Moses, OCD Chief Operating Officer. Once approved by HUD, the anticipated completion date for this corrective action plan will coincide with the closing of the SRPP program.If you have questions or require additional information, please feel free to contact me.

View Audit 312391 Questioned Costs: $1

Finding 433261 (2022-007)

Material Weakness 2022

State of Louisiana

LA

Subrecipient Monitoring § 200.332 § 200.501 § 200.521

Dear Mr. Waguespack,Please find below our management response to the audit finding "Noncompliance with Subrecipient Monitoring Requirements".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 star...

Dear Mr. Waguespack,Please find below our management response to the audit finding "Noncompliance with Subrecipient Monitoring Requirements".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 issued on 5/26/22.? Preliminary response request was issued on 5/26/2022.? Preliminary finding response was submitted on 6/2/2022.? Audit response request letter was submitted on 6/6/22.? Audit response was submitted on 6/13/22.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. Continue with our procedures to adequately monitor subrecipients.2. Implement a risk assessment questionnaire and have Senior SPFAC staff complete one for every sub recipient per 2 CFR 200.332 (f).

View Audit 312391

Finding 433258 (2022-008)

None 2022

State of Louisiana

LA

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

Dear Mr. Waguespack:The Department of Children and Family Services has reviewed the finding ?Improper Employee Activity in Federal Program?. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. Each...

Dear Mr. Waguespack:The Department of Children and Family Services has reviewed the finding ?Improper Employee Activity in Federal Program?. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. Each employee of the Department of Children and Family Services (DCFS), as a new hire and annually, must sign and date form DCFS CS 4 Acknowledgement of Agreement to Comply with DCFS Policy Regarding Prohibited Activities and Employees Working on Cases of Relatives, Friends, Acquaintances, and/or Oneself.The Department?s Fraud and Recovery Unit initiates a review of each employee receiving benefits under the programs administered. An automated monthly report identifies all DCFS employees receiving assistance in the Supplemental Nutrition Assistance Program (SNAP) and all new cases are reviewed for eligibility by parish office staff. Any cases identified by parish office staff as suspect are submitted to the Fraud and Recovery Unit for investigation. Through their reviews, the Fraud and Recovery Unit identified improper activity by a DFCS employee. The employee was subsequently terminated and is required to repay the ineligible SNAP benefits. Additionally, the employee is barred from future employment with DCFS.DCFS reported this finding to the United States Department of Agriculture, Food and Nutrition Service, on the FNS 366B, as required. The Fraud and Recovery Unit has collected $78.00 of the debt and will continue to pursue recovery of the remaining $3,890.00 balance. Should the household cease to repay the balance the case will be referred to the Treasury Offset Program once the due process prerequisites are met.The Fraud and Recovery Unit also investigated two employees for payroll fraud. Both employees were determined to have received wages from DCFS and a secondary employer for the same hours worked. One of the employees was terminated from DCFS and the other employee resigned prior to the receipt of a termination letter. DCFS has recovered $11,349 from one former employee and is seeking recovery of the amount owed by the other former employee.DCFS will continue to investigate improper employee activities and emphasize the consequences of illegal acts. If you have any questions, please contact Rhonda Brown, Fraud and Recovery Unit Director, at Rhonda.Brown.DCFS@LA.GOV.

View Audit 312391

Finding 433257 (2022-006)

Material Weakness 2022

State of Louisiana

LA

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.308 § 200.430

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...

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.

View Audit 312391 Questioned Costs: $1

Finding 433256 (2022-005)

Material Weakness 2022

State of Louisiana

LA

Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

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 f...

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.

View Audit 312391

Finding 425836 (2022-001)

None 2022

Family Health International

NC

Procurement, Suspension & Debarment Subrecipient Monitoring HUD Housing Programs § 200.170

Management has stressed the criticality of prompt submission through comprehensive globalcommunications from the corporate headquarters. This directive will emphasize coordinating withvarious departmental heads to reinforce the requirement across different levels of the organization.Management is im...

Management has stressed the criticality of prompt submission through comprehensive globalcommunications from the corporate headquarters. This directive will emphasize coordinating withvarious departmental heads to reinforce the requirement across different levels of the organization.Management is implementing a worldwide procurement system to structure the current reportingframework.

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Finding 425828 (2022-006)

Material Weakness 2022

Commonspirit Health

IL

Eligibility Internal Control / Segregation of Duties Material Weakness § 200.303

REFERENCE: 2022-006 ? EligibilityHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoSt. Mary Medical Center ? Long BeachFinding: St. Mary Medical Center ? Long Beach and St...

REFERENCE: 2022-006 ? EligibilityHIV Emergency Relief Project Grants (Assistance listing No. 93.914)Federal Grantor: Health Resources and Services AdministrationFacility: St. Mary?s Medical Center ? San FranciscoSt. Mary Medical Center ? Long BeachFinding: St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did notconsistently retain evidence of their internal controls over the requirement to review eligibility requirements prior toadministering services in accordance with the grant agreements.Corrective Action Plan: This finding has been corrected. The 6 month eligibility check is no longer required. Forthe annual eligibility checks at St. Mary?s Medical Center ? San Francisco, all HIV patients are listed on an Excelspreadsheet that is on a shared drive. Both the Social Worker and Case Manager are responsible for monitoring andupdating patient information contained on the spreadsheet. The spreadsheet is monitored and updated daily. Hardcopies of eligibility documents are kept in a locked file cabinet located in the Social Worker?s office. Along with thehard copies, a face sheet listing eligibility documents, patient name and medical record number and name of personwho received the documents is documented. Electronic copies of eligibility documents are kept on the CaseManager?s password protected computer hard drive. The disposition and status of each patient is documented on thespreadsheet. The date documents were last collected is listed in the first column on the eligibility spreadsheet.Patients not participating on the ADAP program are contacted at least 15 days prior to the expiration of eligibilitydocuments on file. Patient contact attempts are documented in the patient?s medical record. In the event the patientdoes not respond to phone calls the patient is sent a certified letter. Patients may be contacted via secure email withthe address on file. The spreadsheet is reviewed weekly. Outreach attempts are documented in the patient?smedical chart. Corrective action was implemented in July 2022.At St. Mary Medical Center ? Long Beach, In April 2022 management implemented a more robust and electronicfile for each client to make it easy to ensure appropriate tracking of eligibility requirements validation. Files arereviewed monthly to ensure compliance.Person Responsible: Toni Luckett, Manager of Nursing, St. Mary?s San FranciscoSharon McNealy, CFO ? St. Mary Long BeachCompletion: April 30, 2022

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Finding 425827 (2022-007)

Material Weakness 2022

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

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 ...

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

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