Corrective Action Plans

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THREE OAKS PUBLIC SCHOOL ACADEMY CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Three Oaks Public School Academy respectfully submits the following corrective action plan for the year ended June 30, 2025. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period Y...
THREE OAKS PUBLIC SCHOOL ACADEMY CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Three Oaks Public School Academy respectfully submits the following corrective action plan for the year ended June 30, 2025. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period Year ended June 30, 2025 Academy Contact Person: Robert Holst, Finance Director Finding 2025-001 – Significant deficiency Recommendation: The Academy should consistently utilize a point-of-sale system to track and claim the number of meals served. The Academy should also maintain documented reviewed records on the meal counts. Action to be Taken: The Academy concurs with the facts of this finding and has implemented procedures to prevent this in the future.
SUSPENSION AND DEBARMENT Federal Agency: U.S. Department of Agriculture Federal Program Name: Child Nutrition Cluster Assistance Listing Number: 10.553 and 10.555 Award Period: Year Ended June 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We rec...
SUSPENSION AND DEBARMENT Federal Agency: U.S. Department of Agriculture Federal Program Name: Child Nutrition Cluster Assistance Listing Number: 10.553 and 10.555 Award Period: Year Ended June 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the District implement additional procedures to ensure suspension and debarment documentation is retained. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to evaluate their policies and procedures and retain documentation of their review. Official Responsible for Ensuring CAP: Todd Tetzlaff, Director of Finance and Human Resources. Planned Completion Date for CAP: June 30, 2026.
Federal Agency: U.S. Department of Agriculture Federal Program Name: Child Nutrition Cluster Assistance Listing Number: 10.553 and 10.555 Federal Award Identification Number and Year: 212MN061N1199 - 2025 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-2174-000 Award...
Federal Agency: U.S. Department of Agriculture Federal Program Name: Child Nutrition Cluster Assistance Listing Number: 10.553 and 10.555 Federal Award Identification Number and Year: 212MN061N1199 - 2025 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-2174-000 Award Period: July 1, 2024 - June 30, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the District review and approve the CLiCS meals counts reports timely and before they are submitted. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The District will ensure that all CLiCS submissions are reviewed and approved before submission. Name of the Contact Person Responsible for Corrective Action Plan: Jolene Bengtson, Business Manager Planned Completion Date for Corrective Action Plan: June 30, 2026
Finding 2025-004 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District will evaluate current procedures for accurately monitoring, recording, and reporting the num...
Finding 2025-004 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District will evaluate current procedures for accurately monitoring, recording, and reporting the number and type of meals served. 3. Official Responsible Mr. Michael Malmberg, Superintendent, is the official responsible for ensuring corrective action. 4. Planned Completion Date June 30, 2026 5. Plan to Monitor Completion The Board of Directors will be monitoring this Corrective Action Plan.
CAP: The District will establish processes and procedures to ensure compliance with executive orders 12549 and 12689, and 2 CFR Part 180 regarding disbarred vendors. Date: June 30, 2025 Who: Michael Cavanaugh, Business Administrator
CAP: The District will establish processes and procedures to ensure compliance with executive orders 12549 and 12689, and 2 CFR Part 180 regarding disbarred vendors. Date: June 30, 2025 Who: Michael Cavanaugh, Business Administrator
Recommendation: We recommend the District implement additional procedures to ensure suspension and debarment documentation is retained. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will cont...
Recommendation: We recommend the District implement additional procedures to ensure suspension and debarment documentation is retained. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to evaluate their policies and procedures and retain documentation of their review. Official Responsible for Ensuring CAP: Heather Hipp, Business Manager Planned Completion Date for CAP: June 30, 2026
Admin Offices 4301 S Cowan Rd Muncie, IN 47302 765-747-5222 office CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2025 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Progr...
Admin Offices 4301 S Cowan Rd Muncie, IN 47302 765-747-5222 office CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2025 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2025 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Significant Deficiency Context: During testing of allowable activities and costs, it was observed that the School Corporation allocated payroll and benefit expenses to the school lunch fund for the employee overseeing the food service management company. Five payroll transactions totaling $5,476 were selected for testing. For each transaction tested, the School Corporation allocated 18% of the employee’s time to the school lunch fund. Although the employee completed an annual self-certification estimating time spent on food service duties, there was no detailed time and effort log to support actual hours worked. Additionally, no internal control existed to provide a documented secondary review of the self-certification for accuracy and completeness. Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: 765-747-5222 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation will no longer charge any payroll and benefit expenses to the school lunch fund. Anticipated Completion Date: July 1, 2025.
View Audit 373490 Questioned Costs: $1
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring C...
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Food and Nutrition Service Coordinator. 4. Planned Completion Date for CAP The CAP was implemented immediately during audit fieldwork performed in October 2025. 5. Plan to Monitor Completion of CAP The Food and Nutrition Service Coordinator will continually review applications and supporting documentation for completion and eligibility accuracy. Any issues noted will be communicated to appropriate staff and fixed immediately.
Implementation plan of action: The Business Manager will review these requirements with the Sr. Account Clerk. The Sr. Account Clerk will verify that all vendors are eligible to participate in the federal assistance program on an annual basis. Specifically, a note will be entered on the vendor recor...
Implementation plan of action: The Business Manager will review these requirements with the Sr. Account Clerk. The Sr. Account Clerk will verify that all vendors are eligible to participate in the federal assistance program on an annual basis. Specifically, a note will be entered on the vendor record in the accounting system each time a purchase order is issued, which will detail that the proper verification was performed. Person Responsible for Implementation: Jodi Birch, Business Manager and Amanda Lestage, Sr. Account Clerk Anticipated Completion Date: August 30, 2025
Views of Responsible Officials and Planned Corrective Action: The District acknowledges the finding and agrees with the recommendation. To address this issue, the following corrective actions will be implemented: The Business Office will verify all vendors used in federally funded programs at least ...
Views of Responsible Officials and Planned Corrective Action: The District acknowledges the finding and agrees with the recommendation. To address this issue, the following corrective actions will be implemented: The Business Office will verify all vendors used in federally funded programs at least once annually and prior to disbursing funds o Persons responsible: Michele Hogan and April Young o Anticipated Completion Date: This process will be completed by June 12th, 2026 ● Staff will review both 2 CFR Section 200.214 and 2 CFR Part 180 for understanding and compliance o Persons responsible: Michele Hogan and John Lybert o Anticipated Completion Date: This will be completed by September 30, 2025
Effective September 15, 2025 the District Treasurer will check the status of all vendors associated to the Child Nutrition program. In cooperation with the Food Service Director, the District Treasurer will review eligibility of any vendors that are requested to be used. Any vendor that is found not...
Effective September 15, 2025 the District Treasurer will check the status of all vendors associated to the Child Nutrition program. In cooperation with the Food Service Director, the District Treasurer will review eligibility of any vendors that are requested to be used. Any vendor that is found not to be eligibility list will be reported to the Food Service Director and Purchasing Agent. This list will be updated and checked annually.
The District will review the requirements of 2 CFR Section 200.214 and 2 CFR Part 180 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. This will be verified on an annual ...
The District will review the requirements of 2 CFR Section 200.214 and 2 CFR Part 180 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. This will be verified on an annual basis. Anticipated implementation date is October 1, 2025 by responsible person(s) District Business Official and District Treasurer Kelsey Reed.
CORRECTIVE ACTION PLAN Finding 2025-001 – Reporting The District concurs with the finding 2025-001. Corrective Action: Moving forward, the District Treasurer will enter the monthly claims with the Food Service Director and will verify that the meal counts and the total claims are correct for both br...
CORRECTIVE ACTION PLAN Finding 2025-001 – Reporting The District concurs with the finding 2025-001. Corrective Action: Moving forward, the District Treasurer will enter the monthly claims with the Food Service Director and will verify that the meal counts and the total claims are correct for both breakfast and lunch. The anticipated completion date of the corrective action is September 29, 2025. Contact Person: Alicia D. Koster, Superintendent of Schools (518) 762-4611 akoster@johnstownschools.org
View Audit 370819 Questioned Costs: $1
The Tallapoosa County Board of Education will implement additional controls to ensure accurate meal counts are reported on Claims for Reimbursement for the School Breakfast Program. Procedures will be strengthened to ensure meal counts are taken daily at the point of service (where students walk thr...
The Tallapoosa County Board of Education will implement additional controls to ensure accurate meal counts are reported on Claims for Reimbursement for the School Breakfast Program. Procedures will be strengthened to ensure meal counts are taken daily at the point of service (where students walk through the cafeteria lines) and verified against student attendance records when preparing reimbursement claims. The Child Nutrition Program staff will review meal count reports prior to submission to ensure the number of meals claimed does not exceed the number of students in attendance. Additional oversight will be provided to ensure compliance with federal Child Nutrition Program requirements.
Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Seco...
Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Second Harvest Food Bank expenses incurred during the fiscal year that should be allocated to the TEFAP/CSFP administrative revenue received. The Organization has historically recognized revenue based on when cash is received which is not appropriate. Recommendation: We recommend the allocation of allowable costs and activities be completed at a minimum on a quarterly basis. Also, any direct expenses related to program activities should be recorded to the respectiveidentifying program fund number within the accounting software. The amount of revenue recognized for the programs should be reflected of the expenses incurred up to the administrative funds received from the respective funders. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization will implement a standard allocation to be completed on a quarterly basis at the minimum. This process will be reviewed by management to ensure implementation. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 2026.
The District Office has established a separate bank account for its Cafeteria Fund in fiscal year 25. The District is also in the process of implementing procedures to ensure cafeteria funds are used exclusively for allowable food service purposes and are properly monitored and reconciled.
The District Office has established a separate bank account for its Cafeteria Fund in fiscal year 25. The District is also in the process of implementing procedures to ensure cafeteria funds are used exclusively for allowable food service purposes and are properly monitored and reconciled.
Talmud Torah Darkei Avos-Monsey respectfully submits the following corrective action plan for the year ended August 31, 2024. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: September 01, 2023 - August 31, 2024 The finding from the August 31, 2024 sched...
Talmud Torah Darkei Avos-Monsey respectfully submits the following corrective action plan for the year ended August 31, 2024. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: September 01, 2023 - August 31, 2024 The finding from the August 31, 2024 schedule of findings and questioned costs is discussed below. Finding 2024-001: Federal Awards Program Audit U.S. Department of Agriculture Child Nutrition Cluster Programs Deficiency: See Finding 2024-001 Recommendation: The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight. Anticipated Completion Date: 05/31/2026 Actions Taken: The Organization has begun implementing the above-mentioned recommendations. The Organization will ensure that it has a working compliance calendar to assist in meeting the reporting deadline. Additionally, the Organization has engaged the audit firm for their upcoming fiscal year-end, and the audit firm has put it on its calendar to begin the audit process well in advance. The Organization’s board of directors has agreed to oversee the auditing and reporting processes to a greater extent. With these actions, the Organization expects to comply with the Uniform Guidance for single audits deadline for the fiscal year end August 31, 2025. Mr. Yaakov Rotenberg, food service director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-371-2476. Contact Person Responsible for Corrective Action: Yaakov Rotenberg, Food Service Director
Finding 2024-001 – Child Nutrition Cluster Condition: Year-end financial reports contained errors related to the recording of receipts and expenditures for the major federal programs. Cause: The District did not have sufficient monitoring procedures in place to ensure accurate and timely review of f...
Finding 2024-001 – Child Nutrition Cluster Condition: Year-end financial reports contained errors related to the recording of receipts and expenditures for the major federal programs. Cause: The District did not have sufficient monitoring procedures in place to ensure accurate and timely review of federal program financial activity. Corrective Action Plan: The District has taken and will continue to take the following corrective actions to address the identified weaknesses: 1. The District has hired and assigned staff with primary responsibility for federal grant management and compliance oversight. 2. Key personnel involved in federal program administration and accounting have received training related to federal grant requirements, internal controls, and monitoring procedures. 3. The District has implemented enhanced internal review procedures, including periodic reconciliation and supervisory review of federal program receipts and expenditures throughout the fiscal year. 4. Management will conduct ongoing monitoring of federal programs to ensure that financial activity is accurately recorded and reviewed prior to year-end reporting. 5. The District will continue to evaluate internal controls annually and adjust procedures as needed to maintain compliance with Uniform Guidance requirements.
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
2024-009 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...
2024-009 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 Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth), testing and calculations of the CBS Food Program's Net Cash Resources Available and their 3 months averages expenditures, the Commonwealth determined the Food Program's net cash resources exceeded their 3 months average expenditures as of June 30, 2024. The Commonwealth calculated both 3-month average operating expenditures and Net Cash Resources Available based on financial statement information provided by CBS Food Program. The Commonwealth's calculations of Net Cash Resources found that the Food Program exceeded their 3 months average expenditures by $2,354,119 as of June 30, 2024. The Pennsylvania Department of Education (PDE) has been communicating with CBS Food Program to develop plans for spending down their excess non-profit food program balance. Recommendation: CBS Food Program should work with PDE to develop a plan to appropriately utilize its resources. In the future, the Food Program should monitor cash resources to ensure they do not exceed maximum thresholds required by federal regulations. Excess food program resources can be used to improve or expand the nonprofit food service for program participants. 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 agrees in principle with this finding; however, disputes the amount of Net Cash Resources Available in Excess of Federal Regulation. Based on the 2025 Year End Balance, CBS Food Program has $1,087,495.35 in cash and $2,106,728.79 in Certificates of Deposits which totals $3,194,224.11 in Net Cash Resources. CBS Food Program's expenditures during the 24-25 Program Year totaled $8,542,614, which results in allowable Net Cash Resources of$2,135,653.50 (three months of total expenditures). More accurately, the expected expenditures for the 25-26 Program Year are $7,167,206, results in allowable Net Cash Resources of $1,791,801.50. Accordingly, Community Benefit Solutions contends that the Net Cash Resources Available in Excess of Federal Regulations is $1,793,571. Prior to the issuance of the Draft Report, Community Benefit Solutions provided PDE with a preliminary Spend Down Proposal based on an expected $2,800,000 in excess funds. The Spend Down Proposal included, among other things, $837,000 set aside for the purpose of equipping Community Benefit Solutions' new headquarters with a commercial kitchen, refrigerator, and freezer (the "Warehouse Buildout"). PDE approved the portion of the Spend Down Plan pertaining to the Warehouse Buildout. The Board of Directors along with Community Benefit Solutions leadership and PDE will continue to coordinate and determine appropriate and allowable actions to spend down Net Cash Resources in accordance with the federal requirements. 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
2024-006 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...
2024-006 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 procurement testing in accordance with Uniform Guidance requirements, we requested that management provide the most recent suspension and debarment assessments for the vendors selected for review. Our analysis indicated that management did not perform these assessments by reviewing the federal government's suspended or debarred vendor list on SAM.gov. Rather, they relied on vendor certifications obtained through the Commonwealth of Pennsylvania, Department of Education, to determine vendor eligibility with respect to suspension or debarment from federally funded programs. Additionally, we observed that the current procurement policy for the CBS Food Program does not outline a formal procedure for evaluating vendors' suspension and debarment status as required by Uniform Guidance. Recommendation: We recommend that management establish and implement a formal process for evaluating vendors regarding suspension and debarment. This process should include regular reviews of the federal government's suspended or debarred list on SAM.gov to ensure that vendors are not suspended or debarred from participating in federal programs. Additionally, management should ensure that all procurement policies and procedures are updated to reflect this requirement. 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 update its current procurement policy to include a suspension and debarment review of all vendors seeking to do business with the organization. Prior to February 13, 2026, Community Benefit Solutions shall conduct a comprehensive review of all current vendors to ensure compliance with these recommendations. Community Benefit Solutions will update procurement policy to include quarterly suspension and debarment review to be conducted by Quality Assurance Associate and signed off on by Warehouse and Purchasing Director. 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
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