Corrective Action Plans

Finding 2022-018: U.S. Department of Agriculture Child Nutrition Cluster: School Breakfast Program, 10.553 National School Lunch Program, 10.555 Special Milk Program for Children, 10.556 Summer Food Service Program for Children, 10.559 Fresh Fruit and Vegetable Program, 10.582 Reporting Significant Deficiency in Internal Control over Compliance The Nevada Department of Agriculture (NDA) did not have adequate internal controls to ensure accurate information was reported to the federal awarding agency. Inaccurate information was reported to FNS. A nonstatistical sample of seven out of a population of 36 reports was selected for testing. The October 2021 FNS-10 report includes annual information (rather than monthly). Line 12b – Membership (Enrollment) of Public Schools was reported as 13. The actual enrollment supported by the underlying documentation of public schools was 22. The NDA accepts these findings and will take corrective action to enhance internal controls to ensure amounts reported to FNS are correct. Corrective action: The NDA has new staff completing data entry and certification of these reports in the federal system that have been extensively trained on required federal reporting. NDA will ensure that additional checks and balances are put in place to review the FNS-10 reports to ensure they match up with appropriate data collected. Date of completion: June 30, 2024

(B) The Department agrees to develop and implement policies and procedures requiring Department staff to perform reconciliations of recipient agencies? and Regional Food Banks? physical inventories to the Web-based Supply Chain Management system to ensure inventory records are complete and accurate. Starting in January 2021 the Department began developing a position description for an Inventory Specialist with the focus of ensuring accurate and thorough accounting of all year-end inventory and reconciliations. The position was hired in April 2021. Due to the implementation of the inventory database and the timing of beginning and ending inventories, the Department anticipates being able to do a full reconciliation of inventories by December 2022. (C) The Department agrees to develop and implement a tracking system for food inventory at recipient agencies and Regional Food Banks using the Web Supply Chain Management system receipts as the basis of food received, including the maintenance of supporting documents. The Department is undertaking an inventory overhaul which includes implementing a new inventory database and creating and hiring an Inventory Specialist. The Department recognized the need for inventory software and started the process of obtaining it in June 2020. In May 2021, the Department received a signed licensing agreement for a new database which is expected to be implemented in six months per an OIT timeline. In addition to the database, the Department recently hired a new Inventory Specialist position. This position will lead the development of policies, procedures, inventory reconciliations, and monthly report management. Once the Inventory Specialist has a comprehensive understanding of federal and state policy and the new database software, the Department will develop policies and procedures, training for partner agencies, and roll out new requirements for the tracking and reconciliation of program inventories.

The Food Bank has updated the weight and has implemented procedures to ensure products are updated annually.

2022-007 Significant Deficiency in Controls over Compliance and Compliance Finding: Double Reporting of Student Counts. Effective January 2022, the Business Manager now reviews all count sheets and ties the counts to the summary report used to submit claims prior to submittal for reimbursement. She did not, however, review the actual claims before submittal and discovered after-the-fact that these duplicate counts had occurred. The review procedures were immediately changed to include reviewing the actual claim submittal before the Food Manager certifies their claims.

2022-006 Significant Deficiency in Controls over Compliance and Compliance Finding: Reporting We are currently working on a tracking system and are in the process of increasing the number of staff who are authorized to file claims.

2022-004 Material Weakness in Controls over Compliance: Activities Allowed or Unallowed We agree with the recommendations and have made improvements to our procedures. The schools were not prepared for the rapid expansion of the food program, not only at our two high schools, but our partner schools' which requested contracted breakfast/lunch food services for their students as well. This unprecedented growth coupled with supply chain issues from food wholesalers, and shortage of employees in the hiring pool, only exacerbated our issues. The audit sample showed a large error rate for one of the schools. We have gone through the entire year for the school(s) individual count sheets. In the event the Michigan Department of Education determines that the identified discrepancies warrant a repayment we have recorded an allowance in the financial statements for the year ended June 30, 2021. Staff were not properly trained in how to complete the count sheets; however, supervisors did not take the time once they saw there was a problem due to everyone trying to simply get the meals served to the children. In addition, there was a lack of oversight of the Food Service Manager by her direct supervisor. At the time of the 2021 audit, when the issue was brought to our attention, we developed new procedures. School staff performing counts have been trained in how to properly complete the count sheets. The Business Manager now reviews all count sheets and ties counts to the summary report used to submit claims prior to submittal for reimbursement. Given that training and implementation of procedures did not fully occur until January 2022, there are errors in counts prior to implementation of the procedures and repeat findings in fiscal year 2021-22. In addition, with the end of the pandemic, beginning with the 2022-23 school year, the schools were able to resume using electronic software to accurately capture the meal counts.

U.S. DEPARTMENT OF AGRICULTURE SIGNIFICANT DEFICIENCY 2022-003: Child Nutrition Cluster ? CFDA No. 10.553, 10.555 and 10.559 Grant period: Year Ended June 30, 2022 Condition and Context: Per review of the Summer Food Service Program summary sheet for April, the incorrect number of breakfasts was reported. Criteria: The District is required to submit the number of breakfasts and lunches served in order to receive reimbursement for them. Cause: The number of meals entered for reimbursement on the summary sheet was incorrect. Effect: If the correct number of meals is not reported the District will not be reimbursed the correct amount. Recommendation: We recommend that the summary sheets used to compile the request for reimbursement is double checked for accuracy as to the number of meals on the daily count sheets. Grantee Response: We concur with the recommendation. In addition, someone will be reviewing all summary sheets before the request for reimbursement is submitted.

Finding 2022-002 (ACFR 2022-001): There were instances in which the number of meals claimed did not agree with the meal count records resulting in an over/under claim. Corrective Action Approved by the Board: Prior to submitting reimbursement claims to the NJ Department of Agriculture, the meals claimed should be verified to the meal count activity records. Method of Implementation: More care will be taken to ensure meals claimed are verified to meal count activity records. Person Responsible for Implementation: Joanne Origoni, Secretary to the Business Administrator. Completion Date of Implementation: 3/9/2023.

Corrective Action Plan 2022-001 This finding is caused by the District?s Food Service Fund?s fund balance being over the USDA?s threshold of 3 months average expenditures. The District is fully aware of this situation and has a spend down plan in place to help alleviate the excess fund balance down to a reasonable level and anticipates the completion date for the corrective action plan be before the end of the 2022-23 fiscal year. The person responsible for the corrective action is Michelle Adams, the food service director. The plan for monitoring adherence is the food service director will work to assess where the fund balance is after all of the projects from the spend down plan are completed.

PROCUREMENT Name of contact person: Lenore Bricco Corrective Action: The district will strive to comply with the procurement statutes. Proposed Completion Date: Immediate.

FINDING 2022-003 Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Numbers: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the reporting compliance requirement. Context: For all four monthly claims selected for testing, there was no formal evidence of the sponsor claim reimbursement summary being reviewed by someone independent of who prepared the sponsor claim reimbursement summary prior to submission. Additionally, we noted that for one claim in the sample of four, the meal counts were overclaimed for the month. In October 2020, the School Corporation overclaimed breakfast by 43 meals and underclaimed lunch by 11 meals. Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Description of Corrective Action Plan: Food Service Director, Brisha Dunbar will verify that the numbers she pulls from E-trition match the amounts that she is claiming for reimbursement. FSD completes a daily edit check form and compares totals to the monthly E-trition report. Once the food service director has the monthly forms completed Southwestern ECA treasurer, Amber Mitchell will review and compare totals before the numbers are submitted to the State. She will initial the totals form along with the FSD and these forms will be kept on file in the FSD?s office. Responsible Party and Timeline for Completion: Food Service Director, Brisha Dunbar and ECA Treasurer, Amber Mitchell ? these changes will be implemented effective March 2023.

The excess Food Service fund balance was due to the additional funding received while the school operated the SFSP, SSO and CACFP programs, along with an excess fund balance from the prior year. Our prior year spend down plan included equipment replacement for the High School cafeteria and food service areas. Due to delays with shipping and manufacturing, the equipment wasn?t delivered and paid for until July 2022, after our fiscal year end. Had the equipment been delivered and paid for prior to year-end, the District would not have incurred an excess fund balance.

Finding Number 2022-002 Internal controls over distributions of USDA Foods to recipients (Material Weakness) Response and Corrective Action Plan: Given the change in distribution approach, use of the Link2Feed website by food recipients was hard to enforce compliance. However, effective immediately, processes will be put in place to ensure all food recipients register on Link2Feed as required. Responsible Person: Janice Roberts, Program Director, under the oversight of John Cruz, Mercy Executive Director. Estimated Completion Date: November 30, 2022

Finding Number 2022-001 Internal Controls over inventory management (Material Weakness) Response and Corrective Action Plan: COVID impacts on the Mercy Brown Bag program's execution and associated inventory documentation was profound, given the need to restructure historical food distribution practices with recipients and the increase of the food provided through the TEFAP program. Priority was given to distribution of the food to recipients, with limited staffing caused by the increased operational workload and social distancing requirements. Program management will implement written documentation standards and processes to ensure all inventory movement is documented and retained, effective immediately. Additionally, periodic inventories will be conducted to ensure that all transactions have been captured. Exploration of a technology solution to enable these processes will be conducted and implemented if determined to be cost-effective. Responsible Person: Janice Roberts, Program Director, under the oversight of John Cruz, Mercy Executive Director. Estimated Completion Date: January 31, 2023

Corrective Action Plan Finding No.: 2022-001 Subrecipient Eligibility Federal Program Name: Food Distribution Cluster CFDA Numbers: 10.565, 10.568, 10.569 Federal Agency: U.S. Department of Agriculture Requirement: The Organization must enter into written agreements with their subrecipient agencies that includes certain information, including references to 7 CFR section 247.4 and a statement that subrecipient agencies are responsible for certain losses. Finding: During the testing of 37 subrecipient agency agreements, we noted 6 that did not have all required information. Questioned Costs: N/A Systemic or Isolated: This instance of noncompliance is systemic with regard to CSFP subrecipient agreements in Kentucky and Illinois. Effect of Finding: The Organization is not in compliance with applicable regulations. Recommendation: We recommend that the Organization update all agreements to include all required information and references. Corrective Action Plan: Management will immediately update all Illinois CSFP contracts with the required language that references 7 CFR section 247.4 and send the updated contracts to all participating Illinois sites for signature and return to Tri-State Food Bank. Contact Person Responsible for Corrective Action: Glenn Roberts, Executive Director Anticipated Completion Date: January 31, 2022

2022-001 Net Cash Resources Corrective Action Plan: The School District will review cafeteria operations throughout 2022-23 and ensure any excess funds will be used to provide additional support to the cafeteria program.

FINDING 2022-003 Contact Person Responsible for Corrective Action: Sue Hart Contact Phone Number: 812-752-8921 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: If the district is a member of, and purchases through, a purchasing cooperative for food and/or supplies, at least one invoice per month from a vendor/cooperative will be reviewed by the Director of Food Services and compared to the approved price lists. A copy of those documents shall be made and shall include any notes/markings made as a part of the review. If discrepancies are identified, the Director of Food Services will communicate the need for correction to the vendor/cooperative and the district Treasurer and CFO. In addition, another invoice will be pulled and reviewed using the same process, continuing until a subsequent invoice is determined to have no discrepancies when compared to the approved price lists. Documentation showing evidence of these reviews will be filed appropriately by the Director of Food Services for easy access throughout the year and for examination during audits. Anticipated Completion Date: May 2023

Child Nutrition Cluster, COVID-19 National School Lunch Program - Assistance Listing 10.555; passed through the Pennsylvania Department of Education; Grant Period - Year Ended June 30, 2022. Planned Corrective Action: Going forward, the Staff Accountant, Kyle Winton, will review food service related grant expenditures schedules with the Food Service Director, Beth Hufnagel, to ensure the schedules are complete and accurate. Person Responsible: Staff Accountant (Kyle Winton) Anticipated Completion Date: Immediately

Finding: Expenditures for certain services exceeding the simplified acquisition threshold were made, and an approved procurement method was not utilized within Assistance Listing #10.555 and #10.553. Response: The Board will implement the following corrective action plan: 1. The Board will use an approved procurement method for these services. 2. The Board will determine if services are provided in this area by other vendors. 3. If other vendors are available, the Board will distribute and advertise request for bids for these services. Anticipated Completion Date: 09-30-2023

Finding #2022-006 ? Child Nutrition Cluster ? Supporting Documentation (#10.553 and #10.555) Federal Grantor ? U.S. Department of Agriculture Pass-through Award Numbers ? 2022-304627-DPI-SB-546 and 2022-3046247-DPI-NSL-547 Pass-through Entity ? Wisconsin Department of Public Instruction Condition: The federal program annually requires performance of sampling and verification of free and reduced price applications. Supporting documentation supporting verification of applicants for free or reduced meals was not available for review. District could not provide documentation supporting that a verification of 3% of all applicants submitted for free or reduced meals was performed. Effect: Sampling and verification procedures are required to be performed annually. Potential to receive an incorrect amount of aid per meal served and students could be charged the wrong price for meals. Cause: The accounting system had notes indicating that sampling and verification procedures may have taken place, however, no supporting documentation was able to be retrieved. Turnover in the business office occurred. Criteria: The District is required to test 3% of all applications submitted for free or reduced meals to ensure their eligibility has not changed since they applied. If their eligibility has changed, then the District must change the student?s status appropriately. Supporting documentation of these sampling and verification procedures should be maintained for future reference. Recommendation: Policies and procedures should be implemented to ensure proper sampling and verification of applicants is performed and that the supporting documentation be maintained. Response: The District will establish policies and procedures proper sampling and verification procedures are performed and the supporting documentation is maintained. Contact Person: Robert Antholine, Phone number: 262-537-2211, Email: rantholine@randall.k12.wi.us Anticipated Completion: June 30, 2023

Finding #2022-005 ? Child Nutrition Cluster ? Unclaimed Meals (#10.553 and #10.555) Federal Grantor ? U.S. Department of Agriculture Pass-through Award Numbers ? 2022-304627-DPI-SB-546 and 2022-3046247-DPI-NSL-547 Pass-through Entity ? Wisconsin Department of Public Instruction Condition: Food service claims were not prepared by the District within the 60-day window for November 2021 breakfast meals and December 2021 lunch meals served. The auditor brought to the District?s attention during August 2022 fieldwork. Based on meals served, the November 2021 breakfast claim was calculated to be for $9,665 and the December 2021 lunch claim was calculated as $23,751. Effect: District did not receive reimbursement for meals served during November 2021 for breakfast meals served and December 2021 lunch meals served. Cause: The District did not have proper procedures in place for submitting monthly claims. The District began contracting with a Food Service Management Company starting in 2021-2022. Criteria: Monthly breakfast and lunch reimbursement claims should be made within the 60-day time frame. Procedures should be in place to ensure accurate claims are made timely. Recommendation: Policies and procedures should be implemented to ensure meals are claimed in compliance with federal requirements and within the 60-day time frame. Response: On January 30, 2023, the District requested a one-time waiver requests with DPI to claim the meals that were previously missed. The November 2021 breakfast claim was for $9,665 and the December 2021 lunch claim was for $23,751. DPI approved payment on the one-time exceptions in February 2023 and payments were made to the District in March 2023. The District will establish policies and procedures to ensure meals are claimed in a timely manner and in compliance with requirements. Contact Person: Robert Antholine, Phone number: 262-537-2211, Email: rantholine@randall.k12.wi.us Anticipated Completion: June 30, 2023

Summary Description - The School District?s food service fund net cash resources exceeded its three months average expenditures by $155,201.99. Corrective Action Plan - That the School District develop a plan to reduce the food service fund's net cash resources below its three (3) month average expenditures. Method of Implementation - Monitor net cash resources. Work with cafeteria staff and administration to identify and create plan to use funds on allowable purchases to reduce net cash. Person Responsible for Implementation - Mr. Matt Sheehan, Superintendent Estimate Completion Date - March 2023, ongoing.

Finding: During a review by the external auditors of the tally sheets utilized by the clubs for meals served and submitted to the finance department for input into the billing system used by the Department of Education (DOE) for reimbursement, it was discovered that an incorrect number of meals was keyed into the system for one club. The number of meals submitted was higher than what the club had originally reported and resulted in an overpayment received from DOE. Corrective Actions Taken or Planned: The organization, with oversight from Kay Ridgard, Controller, immediately contacted DOE and let them know of the error. DOE made the corrective adjustment in their system and recovered the overpayment by reducing the upcoming September 2022 payment due to the organization by the amount of the overpayment received. There was a complete review of the internal process used in the billing of DOE for meals for each location. The process for submission for reimbursement is outlined below with changes highlighted: 1. Tally sheets sent from the clubs are reviewed by the Accounts Payable Associate (Procurement Coordinator when hired) to ensure that there are no addition errors. 2. Numbers from the tally sheets are entered into an Excel file to give summary totals for the organization and this is used by the Accounts Payable Associate to input data into the DOE system. 3. The Controller (or Manager) reviews the excel file before the data is input into the DOE system to ensure it accurately reflects the tally sheets. 4. Data is input in the DOE system and reports are generated showing the accepted submission that will be reimbursed. 5. The Controller (or Manager) performs a second review to ensure the submitted data match the previously reviewed Excel file.

Finding 2022-002 ? Federal and State Findings and Questioned Costs Corrective Action Plan: Edit check reports from the district?s student information syste, Infinite Campus, will be provided on a monthly basis, no later than the 5th of the month for the preceding month. Any errors listed on the reports will be researched and corrected by the Food Service Director or Assisitant Food Service Director. After all meal sales errors are corrected the final reports will be provided to the Director of Business Services no later than the 10th of the month. These reports will be used to make the monthly federal (USDA) food service claims and retained as documentation for the claims. Person(s) Responsible: Director of Business Services and Food Service Director. Timing for Implementation: August 2022.

CORRECTIVE ACTION PLAN - JUNE 30, 2022 Finding 2022-002: Immaterial Compliance Federal Award Finding This finding is caused by the District?s Food Service Fund?s fund balance being over the USDA?s threshold of 3 months average expenditures. The District is fully aware of this situation and has a spend down plan in place to help alleviate the excess fund balance down to a reasonable level and anticipates the completion date for the corrective action plan be before the end of the 2022-23 fiscal year. The persons responsible for the corrective action are Cathy Kierczynski, the food service director and Katy Xenakis-Makowski, Superintendent. The plan for monitoring adherence is the food service director and business manager will work together to assess where the fund balance is after all of the projects from the spend down plan are completed. Condition: This finding is caused by the District?s Food Service Fund?s fund balance being over the USDA?s threshold of 3 months average expenditures. The USDA requires that the ending balance of the non-profit school food service fund does not exceed three months? average of operating expenses [7 CFR Part 210.14(b)]. Corrective Steps Taken: At this time, the District has a spend down plan in place with the State of Michigan to help alleviate the excess fund balance down to a reasonable level. Anticipated Completion Date: At the end of the 2022-23 Fiscal Year. Monitoring: The plan for monitoring adherence is the food service director and superintendent will work together to assess where the fund balance is after all of the projects from the spend down plan are completed. Name of Responsible Person for Further Information: Cathy Kierczynski, Food Service Director and Katy Xenakis-Makowski, Superintendent. Questioned Costs Related to this Finding: None.