Corrective Action Plans

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U.S. Department of Health and Human Services (DHHS) Maryland Department of Health respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below...
U.S. Department of Health and Human Services (DHHS) Maryland Department of Health respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Maryland Department of Health 20XX-XXX Medicaid Cluster – Assistance Listing No. 93.775, 93.777, 93.778 Children Health Insurance Program – Assistance Listing No. 93.767 Recommendation: We recommend that the Department enhance its procedures and internal controls to ensure that overpayments are reported to CMS either in the quarter in which the recovery is made or in the quarter in which the one-year period following discovery ends, whichever is earlier. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Name(s) of the contact person(s) responsible for corrective action: Planned completion date for corrective action plan 20XX-XXX Medicaid Cluster – Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: We recommend that the Department enhance its procedures and internal controls to ensure that RAC desk and field audits are performed timely and that overpayments are recouped. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:. #1: The Department will direct the RAC vendor to begin all new audits using the current universe of available claims from MMIS II including claims from calendar years 2022-2024. This will ensure timely performance of audits and that overpayments are recouped. The Department will direct the current vendor to request the parameters for the claims from the RAC Contract Monitor and support in the transfer of these claims, so that the RAC vendor may begin including them in new audits that begin after April 1, 2025 through the end of their contract. #2: In addition, the RAC Contract Monitor will work with the Office of Contract Management and Procurement (OCMP) to determine if a contract modification is also needed/recommended to ensure timeliness of claims reviewed in RAC audits going forward, and if so, execute the needed contract modification. #3: Finally, the requirement to audit the most recent available claims will be included as language in the new Request for Proposals (RFP) for a RAC vendor that is expected to be issued in 2025. This RFP will be a competitive procurement to select the next contracted RAC vendor, and as such, will ensure this requirement for timely auditing of providers is maintained going forward regardless of which vendor is selected. Name(s) of the contact person(s) responsible for corrective action: Sandy Kick, Director, OMBM and Lynn Price, RAC Contract Monitor Planned completion date for corrective action plan: #1 & #2: June 30, 2025; #3: December 30, 2025 (expected to issue RFP). If the U.S DHHS has questions regarding this plan, please call Sandy Kick at 410-767-5248 or Lynn Price at (667) 208-0776.
U.S Department of Education (USDE) Maryland State Department of Education respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023-June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. Findings...
U.S Department of Education (USDE) Maryland State Department of Education respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023-June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. Findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Maryland State Department of Education 2024-031 Title I- Part A– Assistance Listing No. 84.010 Recommendation: We recommend that the Department review the federal requirements for determining a subrecipient vs a contractor. Their procedures should be updated to ensure that contractual relationship with the vendors are documented in accordance with the federal contracting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MSDE will review federal requirements for determining a subrecipient vs a contractor. The current MSDE procedures will be reviewed for accuracy and modification. Name(s) of the contact person(s) responsible for corrective action: Mary Gable Assistant State Superintendent Division of Student Support and Federal Programs Office (410) 767-0472 Email : Mary.gable@maryland.gov
U.S. Department of Education (USDE) Maryland State Department of Education respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023-June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. Finding...
U.S. Department of Education (USDE) Maryland State Department of Education respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023-June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. Finding is numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Maryland State Department of Education 2024-018 COVID-19 – Education Stabilization Fund – Assistance Listing No. 84.425 C, D, R, U, V W Recommendation: We recommend the Department review and enhance internal controls and procedures to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance. Explanation of disagreement with audit finding: MSDE disagrees with the finding. MSDE provided the requested reports on January 8, 2025. The audit findings were shared with the Department with aggressive turn-around times on March 27, 2025, as the Department staff were in the middle of several critical projects. This did not give an opportunity to the Department to do an in-depth review once again and provide the documentation requested by the auditors. Action taken in response to finding: Regardless of our disagreement, MSDE will review and enhance its Standard Operating Procedures (SOPs) and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance. Name(s) of the contact person(s) responsible for corrective action: Donna Gunning Assistant Superintendent Division of Financial Policy, Planning, Operations & Strategy Krishnanda Tallur Deputy Superintendent Office of Finance and Operations Planned completion date for corrective action plan: June 30, 2025 Page 2 If the USDE has questions regarding this plan, please call Patricia Ramallosa at 410- 767-0103. Approval of Response to the CLA Findings and Recommendations: Document Version Approval Date Approved by Signature Mar 31, 2025 Donna Gunning, Assistant Superintendent of Financial Policy, Planning, Operations & Strategy Mar 31, 2025 Krishnanda Tallur, Deputy Superintendent of Finance and Operations
COVID-19-Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)– Assistance Listing No. 21.027 Recommendation: We recommend the Department implement procedures and internal controls to ensure that it complies with program requirements, that it maintains documentation, and that documentation is r...
COVID-19-Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)– Assistance Listing No. 21.027 Recommendation: We recommend the Department implement procedures and internal controls to ensure that it complies with program requirements, that it maintains documentation, and that documentation is readily available for audit. Explanation of disagreement with audit finding: The items in question are internal journal entries used to reclassify prior year expenditures to the correct accounts. The expenditures tested during the audit period were reviewed and found to be in compliance with program requirements. Journal entries are prepared by one person then reviewed and signed by the chief of accounting for accuracy. The journal entries are then keyed into the accounting system. In the future, MDL will ensure that all journal entries are provided in a timely manner. Action taken in response to finding: Internal controls exist to provide documentation. To ensure compliance, DOL agrees to provide documentation on time for testing. Name(s) of the contact person(s) responsible for corrective action: Sherry Baynes Planned completion date for corrective action plan: Documentation was provided after the deadline for testing,
U.S. Department of the Treasury Department of Housing and Community Development respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023-June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. Th...
U.S. Department of the Treasury Department of Housing and Community Development respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023-June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Housing and Community Development 2024-014 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Recommendation: We recommend that the Department review and enhance supervisor review and approval to ensure that program requirements are consistently performed. Documentation to support compliance with the requirements should be maintained and readily available for review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The subrecipient who administered the assistance for three (3) of the four (4) affected records has fully expended ERA 2 funds. DHCD will review the subrecipient’s internal approvals process and tenant notification process to determine where improvements can be made and issue recommended recordkeeping changes for the subrecipient to implement for future federal subawards. DHCD will review and make necessary changes to program policy guides as necessary to strengthen case file recordkeeping requirements and ensure that case file reviews for direct financial assistance programs include a review of notifications to clients. In prior desk monitoring and file audits, the relevant subrecipient files always included a notification of assistance to the tenant. Name(s) of the contact person(s) responsible for corrective action: Danielle Meister Planned completion date for corrective action plan: April 30, 2025 2024-015 COVID-19 – Homeowner Assistance Fund – Assistance Listing No. 21.026 Recommendation: The Department should reevaluate current process, implement proper controls, and perform additional training over time and effort reporting. The Department should not seek federal reimbursement unless they can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Monthly reporting to Senior Management of any exceptions to the federal timesheet process will be required to ensure that all federal timesheets are completed and received in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Wade Simmons Planned completion date for corrective action plan: April 30, 2025 If the U.S. Department of the Treasury has questions regarding this plan, please call Crystal Quinzani at (301) 429-7840.
Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance. To Whom It May Concern: On behalf of our Team, let me thank you for the support CLA team has provided in the just ended single audit...
Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance. To Whom It May Concern: On behalf of our Team, let me thank you for the support CLA team has provided in the just ended single audit. Please see our response below. Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance DWDAL Response: The Maryland Department of Labor’s Division of Workforce Development and Adult Learning (DWDAL) accepts the FFATA finding. DWDAL was not aware of the aspect of the FFATA requirement that stipulated internal control of a non-Federal entity as per 2 CFR section 200.303(a), and therefore, had not established a protocol. Action taken in response to finding: Develop a policy relating to the FFATA requirements and implement within DWDAL’s Financial Management Handbook and circulated to all Local Workforce Development Areas (LWDAs). Name(s) of the contact person(s) responsible for corrective action: Dorothee Schlotterbeck Planned completion date for corrective action plan: June 28, 2025
Name of Auditee: City of New Rochelle, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Geb Cook, District Manager Phone: (203) 410-8156 (1) Audit Finding 2024-001 - The District did not timely submit the Federal Data Coll...
Name of Auditee: City of New Rochelle, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Geb Cook, District Manager Phone: (203) 410-8156 (1) Audit Finding 2024-001 - The District did not timely submit the Federal Data Collection Form to the appropriate authorities. (a) Implementation Plan of Actions - Management is now aware of the deadline and will work to meet it going forward. (b) Implementation Date - This will be implemented during the year ended December 31, 2025. (c) Persons Responsible for Implementation - The District Manager.
Management Response: To enhance compliance and operational efficiency, OLYCAP engaged a contract manager to support timely fulfillment of reporting obligations and contractual requirements. This role also includes onboarding new management personnel by ensuring they are informed of all relevant cont...
Management Response: To enhance compliance and operational efficiency, OLYCAP engaged a contract manager to support timely fulfillment of reporting obligations and contractual requirements. This role also includes onboarding new management personnel by ensuring they are informed of all relevant contracts and associated reporting protocols. Anticipated Completion Date: April, 2025 and ongoing. Responsible officials: Erin Smith Holly Morgan
2024-002 Reporting Recommendation: We recommend the City resolve issues with the Treasury and ensure it is up to date with the latest reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City...
2024-002 Reporting Recommendation: We recommend the City resolve issues with the Treasury and ensure it is up to date with the latest reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City made every effort to provide annual reports, the City tried to get support from the federal agency's with no response. When the City went in to do the most recent report all of the prior reports had been deleted. Name(s) of the contact person(s) responsible for corrective action: Albert Avila, Finance Director Planned completion date for corrective action plan: 01/22/2026
Due to limited staff size, we do not have adequate segregation of duties in the aeras of financial accounting and reporting as recommended for organizations. We have outsourced a 3rd party bookkeeping firm who provides payroll and payroll tax services and oversight of other various accounting matter...
Due to limited staff size, we do not have adequate segregation of duties in the aeras of financial accounting and reporting as recommended for organizations. We have outsourced a 3rd party bookkeeping firm who provides payroll and payroll tax services and oversight of other various accounting matters as needed. The accounting staff that we do have (one person), is working to minimize the increased work at year-end by improving internal accounting systems with more efficiency and greater consistency. We believe this will help.
(a) Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. (b) Action(s) Taken or Planned: 2024-001: The underfunded replacement reserve deposit will be deposite...
(a) Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. (b) Action(s) Taken or Planned: 2024-001: The underfunded replacement reserve deposit will be deposited into the replacement reserve account as cash flow allows during fiscal year 2025. Furthermore, internal controls over replacement reserve funding are being strengthened to prevent future non-compliance.
Finding 2024-004 – Insufficient Skills, Knowledge and Training, and Leadership (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Env...
Finding 2024-004 – Insufficient Skills, Knowledge and Training, and Leadership (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land ManagementCriteria: Under Uniform Guidance 2 CFR §200.303, non-federal entities must establish and maintain effective internal control over federal awards that provides reasonable assurance of compliance with federal statutes, regulations, and the award terms and conditions. This includes ensuring that:  Personnel administering federal awards possess adequate skills, knowledge, and experience.  Management and leadership provide appropriate oversight of federal award activities.  Financial management systems adequately support accurate reporting, documentation, retention, and reconciliation of federal expenditures in accordance with 2 CFR §200.302. Condition: During the audit of federal awards, the entity did not demonstrate sufficient skills, knowledge, or experience of the staff and leadership responsible for administering and overseeing federal programs. Specifically:  Adequate supporting documentation for federal award expenditures was not maintained or provided.  Leadership oversight of federal award compliance activities was limited, and management review of grant activity were not evidenced. These conditions resulted in weaknesses in financial reporting, compliance monitoring, and documentation related to federal awards. Cause: Partnership for the Umpqua Rivers has not ensured that staffing levels, qualifications, and experience are sufficient to support federal award administration and compliance. In addition, leadership lacks adequate knowledge of federal award requirements to provide effective governance, oversight, and monitoring of compliance activities. Formal training and documented procedures for federal awards management have not been prioritized. Effect or Potential Effect: As a result of these deficiencies:  Partnership for the Umpqua Rivers is at increased risk of non-compliance with Uniform Guidance requirements.  Federal expenditures may be unsupported, inaccurately reported, or unallowable.  Errors or compliance violations may not be detected or corrected in a timely manner.  The entity may be subject to questioned costs, repayment of federal funds, or additional scrutiny from grantor agencies. Questioned Cost: None identified Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. No financial files for Accounts Payable, invoices, or reporting were available to the current financial staff. Not adequately retaining supporting documents and invoices to support the expenditures of the general ledger and requests for reimbursement for grants, the organization records may be insufficient for testing and review, for internal controls or meeting federal documentation and reporting requirements. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Ensure staff responsible for federal awards receive appropriate training on Uniform Guidance requirements, grant financial management, documentation, and compliance monitoring. Assign federal award oversight to personnel with sufficient experience and qualification or obtain external grant management and accounting support as needed.  Establish written policies and procedures for federal award administration, including expenditure documentation, reconciliation, compliance review, and management approvals.  Require leadership to perform and document periodic oversight and monitoring of federal awards, including review of reconciliations reimbursement requests, and compliance metrics.  Implement ongoing monitoring and internal control assessments to ensure compliance with federal award requirements. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: _____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: ___________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager
Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in SEMAP reporting. We accept responsibility for the deficiencies in internal control over SEMAP reporting and are committed to implementing corrective actions that address mis...
Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in SEMAP reporting. We accept responsibility for the deficiencies in internal control over SEMAP reporting and are committed to implementing corrective actions that address missing self-certification documentalion to ensure compliance. The Authority must take immediate steps to remediate these deficiencies by establishing a robust, auditable documentation process: • Strengthen Internal Controls: Develop procedures to ensure complete and accurate documentation is maintained for all 14 SEMAP indicators, including detailed sampling methodologies. • Pre-Certification Review: Implement a mandatory management review process for all SEMAP documentation before final certification is submitted to HUD. • Ensure Proper Retention: Enforce document retention policies that align with HUD regulations, ensuring records are accessible for audit purposes. • Staff Training: Provide training to staff regarding SEMAP indicator requirements and the necessity of maintaining supporting evidence. • Utilize PIG Reports: Ensure all tenant data is properly reported in PlC, as this is the basis for several indicators. Name of Responsible Person: Catherine Lamberg, CEO, and Jackie Otto, COO, and Daporsha Abernathy, HCVP Director Projected Completion Date: Most of the corrective activities are completed. We anticipate completing the balance of activities by May 1, 2026.
Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in its waiting list management. We accept responsibility for the deficiencies in internal control over the waiting list and are committed to implementing corrective actions tha...
Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in its waiting list management. We accept responsibility for the deficiencies in internal control over the waiting list and are committed to implementing corrective actions that address missing documentation and lack of transparency in following the Authority's Administrative Plan and HUD guidelines when selecting applicants from its waiting list. Immediate corrective actions include: • Only using the electronic records of applicants from the Authority's housing software and not creating external waiting lists. • Reconcile and Reconstruct: Immediately reconcile the waiting list and reconstruct missing documentation for voucher issuance. • Cleanup Waiting List: The Authority's waiting list is closed, and staff are currently working to purge it. • Update Procedures: Ensure staff know and are trained on waiting list procedures to ensure compliance with HUD regulations and the Authority's Administrative Plan. • Implement Controls: Establish a periodic supervisory review to verify document completeness during the voucher issuance process. • Training: Provide staff with ongoing training on proper, consistent, and compliant wailing list administration. • Retention: Ensure all records are maintained according to federal retention requirements. Name of Responsible Person: Catherine Lamberg, CEO, and Jackie Otto, COO, and Daporsha Abernathy, HCVP Director Projected Completion Date: Some of the corrective activities are underway. We anticipate completing these activities by June 1, 2026.
Recommendation:We recommend that management develop, implement, and maintain written policies and procedures documenting its system of internal control over federal programs to ensure compliance with Uniform Guidance and applicable federal requirements. Views of Responsible Officials and Planned Cor...
Recommendation:We recommend that management develop, implement, and maintain written policies and procedures documenting its system of internal control over federal programs to ensure compliance with Uniform Guidance and applicable federal requirements. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and plans to develop and implement written internal control policies and procedures over federal programs. Management anticipates completion by June 30, 2026.
Finding: 2024-005 Material Weakness in Internal Control Over Eligibility – WIC Special Supplemental Nutrition Program for Women, Infants, and Children (10.557) Corrective Action: We will develop a checklist for eligibility documentation and conduct quarterly file reviews and implement corrective act...
Finding: 2024-005 Material Weakness in Internal Control Over Eligibility – WIC Special Supplemental Nutrition Program for Women, Infants, and Children (10.557) Corrective Action: We will develop a checklist for eligibility documentation and conduct quarterly file reviews and implement corrective actions as a result of those reviews. We will also provide training to program staff on the eligibility documentation requirements. Proposed Completion Date: February 28, 2026 Name of Contact Person:Tomiko Fisher, Chief Operating Officer
Finding: 2024-004 Material Weakness in Internal Control Over Special Tests – Health Center Program (93.224) Corrective Action: We will develop a checklist for patient discount documentation and implement a control requiring supervisor approval for overrides. We will also perform monthly file audits ...
Finding: 2024-004 Material Weakness in Internal Control Over Special Tests – Health Center Program (93.224) Corrective Action: We will develop a checklist for patient discount documentation and implement a control requiring supervisor approval for overrides. We will also perform monthly file audits and report exceptions to the appropriate personnel. Proposed Completion Date: February 28, 2026 Name of Contact Person: Lane Baker, CHW Chief Operating Officer
Planned Corrective Action: SAVA Center’s new Executive Director added information about the requirements for a single audit to the newly updated financial policies, reflecting that it is the responsibility of the Executive Director to monitor when a single audit is warranted. The Executive Director wi...
Planned Corrective Action: SAVA Center’s new Executive Director added information about the requirements for a single audit to the newly updated financial policies, reflecting that it is the responsibility of the Executive Director to monitor when a single audit is warranted. The Executive Director will maintain a spreadsheet summarizing the Schedule of Federal Expenditures (SEFA) and provide this to the auditor engaged to perform the Single Audit. Name of Contact Person: Alison Jones-Lockwood, Executive Director Anticipated completion date: January 12, 2026
Planned Corrective Action: Prior to the completion of the 2024 Audit, SAVA Center’s Executive Director began revising and updating the organizational financial policies. These policies have been reviewed by the SAVA Center Finance Committee and voted for approval on January 16th, 2026. The updated fin...
Planned Corrective Action: Prior to the completion of the 2024 Audit, SAVA Center’s Executive Director began revising and updating the organizational financial policies. These policies have been reviewed by the SAVA Center Finance Committee and voted for approval on January 16th, 2026. The updated financial policies now contain detailed information on the segregation of duties, which now includes the following people: The Director of Operations (in-house bookkeeper and preparer of grant invoices), the contract Accountant (allocates payroll, prepares monthly financial statements, and assists with preparing the organization budget), the Executive Director (signer of checks, holder of bank card, reviews all grant invoices prior to submission, monitors revenue/expenses, and monthly financials), and the Board Treasurer (reviews and presents monthly financials, signing authority, chairs the finance committee, and provides opinion when needed on accounting best practices). Name of Contact Person: Alison Jones-Lockwood, Executive Director Anticipated completion date: January 16, 2026
2024-012 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...
2024-012 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth) review of CBS Food Program's financial accounting system, it was noted that the Food Program utilizes QuickBooks software for their accounting system. Based on inquiry with CBS Food Program management, we determined internal controls connected with their QuickBooks accounting software were insufficient in the following areas: • User Access Management: Formal written policies or procedures have not been developed and implemented related to access authorization, access monitoring, and removal of system access. Additionally, certain functions are not properly segregated as users have access to perform both input and authorization of transactions. • Input Management: Formal written policies or procedures to ensure information input into QuickBooks is appropriate and accurate have not been developed and implemented. • Change Control Management: A formal written change management policy for QuickBooks Accounting System has not been developed and implemented including requirements that system security updates are implemented timely. • Backup and Recovery: A formal written policy for regular backup and recovery testing has not been developed and implemented. Recommendation: We recommend that CBS Food Program develop and implement comprehensive written internal control policies and procedures connected with their QuickBooks Accounting System. This should include: • Development and utilization of an Accounting Manual which includes an outline of CBS Food Program's accounting rules, procedures, and guidelines. • Access control policies and procedures to ensure that user access to QuickBooks is appropriate, regularly reviewed and promptly revoked upon termination or when otherwise merited. Recommendation (Continued) • A formal written change management policy for QuickBooks should be developed and implemented including requirements that systems security updates are implemented timely. • A disaster recovery plan and procedures to perform periodic testing to ensure that plans are functional and mitigate the risk of extended downtime. This process should also include regular review of backup records to ensure they are appropriately created and maintained. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions does not dispute this finding. Community Benefit Solutions will migrate from Quickbooks Desktop to Quickbooks Online, which will provide a perfect transitional opportunity to re-evaluate processes, and to develop and implement necessary controls over its systems. Community Benefit Solutions will work with independent auditors, internal information technology team, and, if necessary, legal counsel to plan, draft, and implement the relevant internal controls. Planned completion date for corrective action plan: June 30, 2025
2024-011 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...
2024-011 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth) review of CBS Food Programs banking policies, it was noted that the CBS Food Program did not establish appropriate controls to ensure bank account access changes and bank account closures could be promptly completed when organizational or personnel changes merited such actions. CBS Food Program management noted two instances during the engagement period in which lack of cooperation from parties with CBS Food Program bank account authority or access prevented the Food Program from closing bank accounts in an expeditious manner. This resulted in the CBS Food Program simultaneously having bank accounts open at three different banks for a portion of the audit period. As of May 2025, CBS Food Program only actively banks with one institution. Of the accounts with the other institutions, one account is closed, and the other remains open, but inactive because CBS Food Program has not initiated any account-related activity for an extended period of time. According to CBS Food Program management, they are working to close the inactive account, but closure requires assistance from Congregation Beth Solomon which has not been cooperative. The Commonwealth noted that CBS Food Program has inefficient control procedures in place over the issuance of high-value checks. Following the separation of CBS Food Program's prior CEO, the Food Program opened a new bank account in order to remove the prior CEO's access to food program funds. The former CEO was not cooperative in removing his access to the bank account the Food Program used at the time of his separation, so CBS Food Program determined moving the Food Program's funds to a new bank was in the best interest of the organization. To move the Food Program's funds from the old bank to the new bank, CBS Food Program's Director of Finance wrote two checks for $1.5 million dollars each. While CBS Food Program's Director of Finance obtained approval from the board prior to preparing and depositing the checks in the new bank account, a secondary signature was not obtained as CBS Food Program policy did not require a second signature for any check regardless of amount. Recommendation: CBS Food Program should assign bank authorization and access roles to appropriate CBS representatives to ensure access is appropriately limited, but that changes to account authorization can be completed timely when organizational or personnel changes merit such modifications. CBS Food Program should establish, document, and adhere to, a policy requiring documented prior approval and dual signatures on checks exceeding a predetermined threshold set by management and/or the board of directors. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Planned completion date for corrective action plan: June 30, 2025 Action taken in response to finding: Community Benefit Solutions does not dispute this finding and provides the following for the purpose of additional clarification. Between February 14, 2024, and June 10, 2024, the departure of the Farmer CEO and several key Board members resulted in the absence of authorized signers. In order to expeditiously remove individuals from accessing bank funds during this transition, the Community Benefit Solutions Board of Directors granted the Accounting Associate authority to sign all relevant checks and take steps necessary to remove those individuals. Going forward, Community Benefit Solutions will, with the assistance of either Board-approved counsel or outside independent audit firm, develop and implement thresholds for dual signature requirements. Moreover, Community Benefit Solutions will work with JP Morgan Chase Bank to ensure that authorization and authority can be expeditiously amended in the event such a need arises.
2024-010 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...
2024-010 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on interviews by the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (“Commonwealth”) with CBS Food program management, inspection of records, and on-site observations, we identified internal control deficiencies in the following areas: • For a portion of the audit period, there was a lack of segregation of duties between the cash receipt, bookkeeping, and bank reconciliation processes. The Director of Finance was responsible for all these tasks. The Director of Finance was also responsible for both processing and approving payroll and had authorization to make purchases, make vendor payments, record accounting transactions and complete bank reconciliations. • CBS Food Program performs bank reconciliations; however, they are not signed or dated by the individual performing the reconciliation and a second individual does not review or sign off on the reconciliations. Of nine reviewed account reconciliations, three were completed more than 30 days after the statement period end date. • According to CBS Food Program's former Purchasing Distribution Manager, as of June 2024, they were the only CBS Food Program's employees with detailed knowledge of developing monthly menus and creating purchase orders based on current inventory levels to meet menu requirements. Additionally, the former Purchasing Distribution Manager stated that as of June 2024 formal training on internal purchasing policies and procedures is not provided or required. Condition (Continued) • For a portion of the engagement period, CBS Food Program lacked written policies or procedures for several key business functions including: o No written Accounting Manual or Standard Operating Manual for accounting functions. o No written policy or procedure for the use of credit cards or the handling of lost or stolen credit cards. o No written policy or procedure to analyze account balances to ensure transactions have been properly recorded. o No written records retention policy. o No written procedures for handling payroll for separating employees. o No written or implemented review process for changes to the payroll system including changes to employee payrates. o For a portion of the engagement period, the Food Program did not have procedures to o Prior to July 1, 2024, CBS Food Program did not have documented procurement procedures. On July 1, 2024, CBS Food Program implemented a procurement plan. Recommendation: If not already addressed, CBS Food Program should develop and implement improved internal controls including: • Develop written policies, procedures and/or manuals for accounting functions. • Develop a formal internal control policy and framework that focuses on key business and operations areas including segregation of duties, transaction review and approval processes, and monitoring procedures over critical operational functions. • Improve cross training of employees including training on purchasing and accounting tasks. • CBS Food Program should develop and implement a record retention policy that complies with food program requirements for maintaining documentation of operations. The policy should ensure key records are maintained in a shared location accessible to all appropriate personnel. This ensures the CBS Food Program does not lose access to key records in the event an employee leaves the food program. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions will work with its outside independent audit firm, Board-approved counsel, and other necessary stakeholders to develop and implement all the necessary controls as required by the Comptroller. Community Benefit Solutions' implementation of any of the noted changes will be the ability to recruit Finance Committee and Nutrition Committee members of the Board. Moreover, Community Benefit Solutions made strides in implementing some of the requested policies during the Audit. Community Benefit Solutions will endeavor to meet each of the requests despite any lack of human capital that would allow for ease of segregation of authority. Community Benefit Solutions is optimistic that incoming Board Members and external accounting, audit, HR, and legal will provide critical support. Planned completion date for corrective action plan: June 30, 2025
2024-007 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...
2024-007 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of subrecipient monitoring activities for PDE programs CACFP, NLSP, and SFSP, we selected 31 contracted centers at random. Management provided documentation for each site, including contracts, meal pattern usage records, licensure and training documentation, and both announced and unannounced meal observation reviews. However, we found that CBS Food Program did not always maintain sufficient evidence to prove required monitoring was performed under the CACFP program. For one center, management could not produce proof that meal observation reviews or the mandated two unannounced visits occurred. At another center, neither a contract nor any meal observation review records, including the two required unannounced visits, could be provided. For the NLSP and SFSP, management was unable to provide contracts for any of the seven sampled centers. Additionally, there was no evidence of training for one center, and a second center had a noncompliant monitoring visit; although corrective action was prepared, follow-up occurred only after 66 days instead of within the required 45-day window. Recommendation: We recommend that management strengthen internal controls to ensure all required PDE CACFP, NLSP and SFSP subrecipient monitoring activities, including scheduled meal observations and the mandated unannounced visits—are consistently performed, documented, and retained. Management should implement a centralized tracking system to monitor review deadlines, required follow up actions, and receipt of supporting documentation from each contracted center. In addition, staff responsible for monitoring should receive periodic refresher training on PDE CACFP, NLSP and SFSP specific expectations. Finally, management should conduct periodic internal reviews to verify that monitoring documentation is complete, compliant, and appropriately maintained. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions shall utilize internally developed Quickbase application to schedule and track monitoring visits including ensuring necessary corrective action follow-ups are conducted within 45 days documented corrective action needed. Moreover, Community Benefit Solutions will require all monitoring staff to successfully complete monitoring specific training in addition to the annual and civil rights training to ensure up to date knowledge of all requirements. Trainings will be assigned, monitored and signed off on by Director of Operations. Planned completion date for corrective action plan: June 30, 2025
2024-005 Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of participant eligibility, we selected a sample of 40 participants receiving me...
2024-005 Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of participant eligibility, we selected a sample of 40 participants receiving meals at centers contracted with the CBS Food Program. For 2 of the 40 participants, management was unable to provide complete and valid eligibility documentation. In one instance, the only available eligibility form had been prepared in a future fiscal year, and in another instance, the eligibility form could not be located at all. Recommendation: We recommend that management strengthen its CACFP eligibility documentation procedures to ensure that all required forms are properly completed, collected, and retained for every participant. This should include implementing a standardized intake process, maintaining timely reviews to confirm completeness of eligibility files, and developing a tracking or monitoring system to identify missing or outdated documentation. Management should also reinforce internal expectations for timely updating of eligibility files and ensure staff are trained on CACFP documentation requirements. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: On February 1, 2025, Community Benefit Solutions rolled out the KidKare software system wide. KidKare is a CACFP software that allows Community Benefit Solutions to digitally process all eligibility-documentation, standardize the enrollment procedures, ensure forms are completed in accordance with the relevant regulations, request updated documentation upon the expiration of enrollment forms, and digitally store all the eligibility related information for all participants. Planned completion date for corrective action plan: June 30, 2025
The City will implement procedures to ensure accurate SEFA preparation
The City will implement procedures to ensure accurate SEFA preparation
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