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 pioid-STR – Assistance Listing No. 93.788 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:
U.S. Department of Health and Human Services Department of Human Services 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 fi...
U.S. Department of Health and Human Services Department of Human Services 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 Human Services Low-Income Home Energy Assistance Program – Assistance Listing No. 93.568 Recommendation: The Department should review and enhance its procedures and internal controls to ensure that it charges expenditures to the program that are incurred within an award’s allowable period of performance. Explanation of disagreement with audit finding: No disagreement. Action taken in response to finding: The Department has made changes in the Office of Budget and Finance Leadership team and continues to do so at every level. The Department will review and enhance its procedures and internal controls to ensure that it charges expenditures to the program that are incurred within an award’s allowable period of performance. Currently, expenditures are recorded in the State’s Financial Management Information System (FMIS) with program cost accounting codes used to identify the funding source(s) for each activity. The system-generated report summarizes the information and includes the effective date of the activity. In turn, this same report is used to run the cost allocation to properly charge the exact costs to the funding source. Currently information is manually inputted into multiple spreadsheets to prepare the federal reports resulting in the possibility for errors. This significantly impedes the accuracy of the data being reported to federal grants and the provision of supporting documentation. As such, the Department will partner with external consultants to develop a better and more seamless recording structure for grant expenditures to the general ledger. This structure will require quarterly review by the Deputy Cost Allocation Revenue Management Director (CARM), the Cost Allocation Revenue Management Director, and the Deputy Chief Financial Officer. The Department will create a database and document repository to track the submission and reconciliation for federal grant reporting. The document repository will include the FMIS generated report and the cost allocation results table. Upon submission to the federal grant
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 2024-023 Special Education Cluster– Assistance Listing No. 84.027, 84.173 Recommendation: The Department should review and enhance its procedures and internal controls to ensure that it charges expenditures to the program that are incurred within an award’s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MSDE will review and enhance its Standard Operating Procedures (SOPs) and internal controls to ensure that it charges expenditures (including accounts payable and payroll) to Federal programs that are incurred within an award’s allowable period of performance. Name(s) of the contact person(s) responsible for corrective action: Neeta Gandhi Executive Director Office of Program Fiscal Operations and Local Strategic Finance Jenna Meinl Director Office of Procurement and Contract Management Planned completion date for corrective action plan: June 30, 2025 If the USDE has questions regarding this plan, please call Patricia Ramallosa at 410- 767-0103. Page 2 Approval of Response to the CLA Findings and Recommendations: Document Version Approval Date Approved by Signature 1.0 Mar 29, 2025 Neeta Gandhi, Executive Director-Office of Program Fiscal Operations & Local Strategic Finance Mar 29, 2025 Jenna Meinl, Director-Office of Procurement and Contract Management Mar 29, 2025 Donna Gunning, Assistant Superintendent of Financial Policy, Planning, Operations & Strategy Mar 29, 2025 Shawn Rushing, Assistant Superintendent of Administration Mar 29, 2025 Krishnanda Tallur, Deputy Superintendent of Finance and Operations
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,
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
Department of Labor (DOL)Financial Statement Preparationinancial Statement Preparation. Unemployment Insurance – Assistance Listing No. 17.225 Recommendation: We recommend the Department implement procedures and internal controls to ensure that it complies with program requirements, that it maintain...
Department of Labor (DOL)Financial Statement Preparationinancial Statement Preparation. Unemployment Insurance – Assistance Listing No. 17.225 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: There is no disagreement with the audit finding. Recommendation: We recommend the Fund establish procedures to ensure that financial reporting is performed in a timely manner and provide accurate and relevant information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The team that was assembled to work through the audit has also been enlisted to redesign the process and build new tools to create UI Trust Fund financial statements every month. While this is still in development, we plan to have it functioning accurately by May of 2025. Name(s) of the contact person(s) responsible for corrective action: John Fahnbutu. Planned completion date for corrective action plan: 5/30/2025 Recommendation: We recommend the Fund establish procedures to ensure that financial reporting is performed in a timely manner and provide accurate and relevant information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The team that was assembled to work through the audit has also been enlisted to redesign the process and build new tools to create UI Trust Fund financial statements every month. While this is still in development, we plan to have it functioning accurately by May of 2025. Name(s) of the contact person(s) responsible for corrective action: John Fahnbutu. Planned completion date for corrective action plan: 5/30/2025 Maryland Department of Labor- Unemployment Insurance Trust Fund (the Fund) 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—FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS
Corrective Action Taken: Controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Corrective Action Taken: Controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
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
Finding 2024-004: Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Name of Contact Person: Courtney Hoiby, Interim Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and tim...
Finding 2024-004: Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Name of Contact Person: Courtney Hoiby, Interim Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely reported. Completion Date: September 30, 2026
Finding 2024-006 – Compliance; Internal Control over Compliance, Reporting (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 Environ...
Finding 2024-006 – Compliance; Internal Control over Compliance, Reporting (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 AgricultureFederal 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 Management Criteria: Under 2 CFR 200, recipients must submit performance and financial reports as required by the terms and conditions of the award and must retain records sufficient to demonstrate compliance (see (§200.301Monitoring and reporting program performance, and §200.328 Financial reporting, §200.329 Monitoring and reporting program performance, and §200.334 Retention requirements for records). The grant agreements for awards above require timely submission of performance / progress reports by specified due dates, with documentation maintained to support the submitted information. Condition: For the fiscal year ended June 30, 2024, the auditee could not provide sufficient evidence that required reports for the programs listed were prepared, reviewed, and submitted in accordance with grant terms. Specifically:  No provided required financial reports, and Partnership for the Umpqua Rivers lacked copies or evidence of submission, and support for reported amounts requested.  Auditors were not provided with performance/progress reports and were instructed that Partnership for the Umpqua Rivers had no retained copies, review sign-offs, or submission confirmation.  Where payments were received, support for the required reports or metrics were not retained and could not be supplied to auditors for reconciling to underlying records. Cause: Management has not implemented formal reporting controls, including:  A documented reporting calendar with due dates and responsible staff,  Reconciliation of report amounts to the accounting records,  Retention procedures for report copies, underlying support, and submission confirmations, and  Supervisory review evidenced by signatures or workflow approvals. Effect or Potential Effect: Absent evidence of timely, accurate reporting and adequate record retention:  The organization is at risk of noncompliance with federal award conditions,  Inaccurate financial or performance information may be reported to the funding agency, and  The entity may be subject to remedial actions, including heightened monitoring, repayment of questioned amounts, or potential suspension of funding. Questioned Cost: None directly noted, but potential risk if reports were incomplete or inaccurate.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. Award files provided to auditors did not contain information related to reporting of activity, expenditures, or progress of the awards. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Establish a formal reporting and retention policy aligned with 2 CFR 200 and grant terms.  Implement a centralized reporting calendar that tracks due dates, preparers, reviewers, and submission methods.  Require reconciliations of financial reports to the general ledger and supporting schedules, retain the reconciliation with the reporting package.  Create standard workpapers for performance metrics for each award.  Configure the grant portal or document management system to retain submission confirmations, reports, receipts, and version -controlled copies of all reports for awards.  Document supervisory review through sign-offs prior to submission and with evidence retained.  Provide training to staff on Uniform Guidance requirements and record retention (§200.334). 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
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
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: 2024-003 Material Weakness in Internal Control Over Allowable Costs/Cost Principles and Reporting – WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (10.557, 93.268) Corrective Action: We will work to ensure that the proper...
Finding: 2024-003 Material Weakness in Internal Control Over Allowable Costs/Cost Principles and Reporting – WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (10.557, 93.268) Corrective Action: We will work to ensure that the proper indirect cost rate is applied to the various grants. Proposed Completion Date: February 28, 2026 Name of Contact Person: Tomiko Fisher, Chief Operating Officer
Finding: 2024-002 Material Weakness in Internal Control Over Period of Performance – Health Center Program, WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (93.224, 10.557, 93.268) Corrective Action: The District is in the process ...
Finding: 2024-002 Material Weakness in Internal Control Over Period of Performance – Health Center Program, WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (93.224, 10.557, 93.268) Corrective Action: The District is in the process of developing a comprehensive year-end closing checklist and has already streamlined many of the procedures that caused reconciliation issues. In addition, we will perform spot checks on transactions to ensure that payroll and nonpayroll expenditures are recorded in the proper period. We will also provide additional training to ensure that personnel only record expenditures when confirmation has been received of receipt of goods or services. 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
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
2024-005 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
2024-004 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...
2024-004 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 As part of our audit procedures, we selected a sample of 40 payroll transactions for review. This process included examination of employee human resource files (such as signed W-4 and I-9 forms), management-approved pay rates, time sheets with supervisory sign-off, and corresponding payroll reports. We recalculated total hours per timesheet using the employees' pay rates and compared these figures to the relevant payroll reports. During our review, we observed that two employees received additional compensation ranging from $25 to $75 for undertaking extra responsibilities related to the administration of the CBS Food Program’s Summer Food Service Program by the former Chief Executive Officer. Management was unable to provide supporting documentation evidencing approval by the former Chief Executive Officer or confirmation from the Commonwealth of Pennsylvania, Department of Education, indicating that such additional compensation complied with the contractual agreement governing the Summer Food Service Program. Additionally, of the 40 payroll transactions sampled, we noted one employee’s required payroll change documentation (e.g., an approved payroll change form) was not present in their personnel file. Recommendation We recommend that management improve internal controls for payroll authorization by making sure every payroll change form and supplemental compensation approval is filled out, approved, and kept on file. Introducing a central electronic document management system will help securely store records, standardize documentation, and create clear audit trails for all payroll and personnel files. Management should also regularly review payroll records to confirm that all necessary paperwork, such as personnel forms, pay rate approvals, and backup for extra pay, is included. 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 repeats the actions to be taken in response to finding 2024-003 and adds the following: Community Benefit Solutions will utilize ADP document management capabilities to maintain employee files including, but not limited to, Payroll Change Forms or other documentation related to modifications or supplements to employee pay. Community Benefit Solutions will ensure complete upload of all paper files to the appropriate employee profile within ADP to ensure documentation can be readily accessible by those with necessary authorization. Planned completion date for corrective action plan: June 30, 2025
2024-008 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of the reporting requirem...
2024-008 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of the reporting requirements for the CBS Food Program under the National School Lunch Program (NSLP) and Summer Food Service Program (SFSP), management is responsible for submitting the FNS 10 (NSLP) and FNS 418 (SFSP) reports within 30 days after month-end. However, management was unable to provide five (5) monthly NSLP reports and one (1) monthly SFSP report requested for audit testing. Recommendation: The Organization should establish and enforce strengthened internal controls over federal reporting to ensure that all required monthly reports (FNS 10 and FNS 418) are: (a) completed accurately, (b) submitted on time, and (c) retained in accordance with federal record retention requirements (2 CFR 200.334). Management should designate responsible personnel and implement a monitoring process to ensure compliance. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Effective, July 1, 2024, Community Benefit Solutions no longer administers the National School Lunch Program. In the event Community Benefit Solutions should begin administering the NSLP, Community Benefit Solutions will develop and implement requisite policies and procedures to ensure proper reporting requirements including, but not limited to, completion and submission of the FNS10. Planned completion date for corrective action plan: June 30, 2025
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for severa...
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for several years. On July 27, 2025, the building experienced a roof leak causing a catastrophic flood. The building was evacuated and the Office of State Superintendent (OSSE) notified. OSSE sent an inspector to the site the following day who declared the building unsafe for occupancy. The Church was unable to cover any costs for the necessary repairs. On July 30, 2025 the Board of Directors made the difficult decision to suspend operations, but to continue as a Board, maintain the Center’s 501(c)3 status and its corporate registration. Furthermore, the Board is using this time to research current community needs, space availability and cost, and the effect of the Federal government’s waning support for early childhood education. Once this exercise is complete, the Board will determine the Center’s ability to reopen in an alternate site and address the findings in an appropriate manner.
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for severa...
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for several years. On July 27, 2025, the building experienced a roof leak causing a catastrophic flood. The building was evacuated and the Office of State Superintendent (OSSE) notified. OSSE sent an inspector to the site the following day who declared the building unsafe for occupancy. The Church was unable to cover any costs for the necessary repairs. On July 30, 2025 the Board of Directors made the difficult decision to suspend operations, but to continue as a Board, maintain the Center’s 501(c)3 status and its corporate registration. Furthermore, the Board is using this time to research current community needs, space availability and cost, and the effect of the Federal government’s waning support for early childhood education. Once this exercise is complete, the Board will determine the Center’s ability to reopen in an alternate site and address the findings in an appropriate manner.
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