Corrective Action Plans

Finding 497954 (2023-001)

Significant Deficiency 2023

PA

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority has updated the practice to follow the HUD compliance supplement. Linda Kaufman, Executive Director, is responsible for implementing this corrective action by Decembe...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority has updated the practice to follow the HUD compliance supplement. Linda Kaufman, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

View Audit 320577

Finding 497950 (2023-001)

Significant Deficiency 2023

Western Indiana Community Action Agency, Inc.

IN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Corrective Action Plan for Current Year Findings Finding 2023-001: Timely Processing of Participant Applications: Department of Health and Human Services - AL #93.568 Low Income Home Energy Assistance Program #Ll-023-024 Corrective Action: WICAA has developed a streamlined approach for assessing i...

Corrective Action Plan for Current Year Findings Finding 2023-001: Timely Processing of Participant Applications: Department of Health and Human Services - AL #93.568 Low Income Home Energy Assistance Program #Ll-023-024 Corrective Action: WICAA has developed a streamlined approach for assessing incoming applications, differentiating between complete and incomplete applications at the beginning of the processing cycle. This will ensure that complete applications can be promptly processed. Additionally, if a substantial number of unprocessed applications are nearing 10 days of the deadline for processing, our staff will be notified that there is a need for overtime. Overtime requirements will be assessed weekly. These modifications are anticipated to result in applications being processed within the allowable number of days. Person Responsible: The Energy Assistance Director has primary responsibility with oversight by the Executive Director. Timing for Implementation: Immediately

View Audit 320570

Finding 497922 (2023-002)

Significant Deficiency 2023

Stevens County

WA

Reporting Significant Deficiency

Report was entered with project complete marked, and Administrator failed to zero out current period expenditures and obligations from previous reporting. The Administrator believes these were corrected in the report filed in 2024. The Administrator will have Auditor-Treasurer review the final repor...

Report was entered with project complete marked, and Administrator failed to zero out current period expenditures and obligations from previous reporting. The Administrator believes these were corrected in the report filed in 2024. The Administrator will have Auditor-Treasurer review the final report before submitting.

View Audit 320535

Finding 497904 (2023-001)

Significant Deficiency 2023

Howard County Housing Commission

MD

HUD Housing Programs Eligibility Significant Deficiency

Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Eligibility Recommendation: We recommend that the Commission review its process for collecting third party income support to ensure the accurate data is used as part of the tenant rent and HAP calculations. Explanation of disagreement with audit...

Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Eligibility Recommendation: We recommend that the Commission review its process for collecting third party income support to ensure the accurate data is used as part of the tenant rent and HAP calculations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Corrected data is essential in determining the correct rent responsibility and HAP. To ensure that the data and rent calculations are correct, HCHC has taken the following steps: • Staff members have taken additional Housing Specialist training offered by Nan McKay. • HCHC has created and hired a quality control specialist who selects housing specialist 50058 actions to ensure that HCHC has data integrity, and all information is true and accurate. • The supervisor also selects housing specialist 50058 actions for review, ensuring that all required documentation is intact and that the proper rent responsibility and HAP calculations are correct. Name(s) of the contact person(s) responsible for corrective action: Crystal Gorham, Director of Rental Assistance Completion date for corrective action plan: 6/30/2024

View Audit 320485

Finding 497899 (2023-002)

Significant Deficiency 2023

Sawyer County Housing Authority

WI

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency

Recommendation: We recommend, the entity develop a method to track actual time spent on various programs to time allocated to federal award programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Auth...

Recommendation: We recommend, the entity develop a method to track actual time spent on various programs to time allocated to federal award programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will work on developing proper time and effort documentation. Name of the contact person responsible for corrective action: Sheila Young Planned completion date for corrective action plan: December 31, 2024

View Audit 320468

Finding 497898 (2023-001)

Significant Deficiency 2023

Sawyer County Housing Authority

WI

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Recommendation: We recommend that Authority implement procedures to verify reinspections done within 30 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will review processes to make sure...

Recommendation: We recommend that Authority implement procedures to verify reinspections done within 30 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will review processes to make sure all reinspections are done within the required time. Name of the contact person responsible for corrective action: Sheila Young Planned completion date for corrective action plan: December 31, 2024

View Audit 320468

Finding 497897 (2023-001)

Significant Deficiency 2023

Hamlet Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Hamlet Housing Authority Corrective Action Plan For the Year Ended December 31, 2023 Section II - Financial Statement Findings None Reported. Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Gary Jones Executive Director Corrective Action: Man...

Hamlet Housing Authority Corrective Action Plan For the Year Ended December 31, 2023 Section II - Financial Statement Findings None Reported. Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Gary Jones Executive Director Corrective Action: Management will review the recertification process and plan to monitor recertifications. Proposed Completion Date: Immediately

View Audit 320466

Finding 497621 (2023-001)

Significant Deficiency 2023

Bladenboro Housing Authority

NC

HUD Housing Programs Eligibility Reporting

Corrective Action Plan For the year ended December 31, 2023 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Becky Tatum Interim Director Corrective Action: Mangagement will implement pr...

Corrective Action Plan For the year ended December 31, 2023 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Becky Tatum Interim Director Corrective Action: Mangagement will implement proper internal control procedures for the Housing Choice Voucher Program eligibility requirements. Proposed Completion Date: Immediately

View Audit 320414

Finding 497620 (2023-001)

Significant Deficiency 2023

South Carolina Regional Housing Authority No. 1

SC

HUD Housing Programs Eligibility Significant Deficiency

Finding No. 2023-001 Eligibility: Public Housing Tenant Files Public and Indian Housing Program – CFDA Number 14.850 Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Condition: Out of a total tenant population of 1,275, 25 files were sel...

Finding No. 2023-001 Eligibility: Public Housing Tenant Files Public and Indian Housing Program – CFDA Number 14.850 Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Condition: Out of a total tenant population of 1,275, 25 files were selected for testing. Exceptions were noted as follows: • 3 out of 25 tenants where an outdated flat rent was used instead of the current amount. • 1 tenant where wage income was calculated as paid bi-weekly when it was actually paid semi-monthly. • 2 tenants where the prior year social security income was used when the current year amount was known. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding and will implement review procedures and provide ongoing training to staff. The cited files have been corrected. Effective Date: September 19, 2024 Contact Information Brian Griswell, Executive Director SC Regional Housing Authority No.1 218 Spring Street Laurens, SC 29360 (864) 984-6568

View Audit 320403

Finding 497611 (2023-001)

Significant Deficiency 2023

Serenity House Counseling Services, Inc.

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Serenity House has followed up with corrective actions to include – Personnel changes in the Bookkeeping role. In addition, we have upgraded our Quick Books to better help with reporting. We have upgraded to Quick Books Online.

View Audit 320380

Finding 497528 (2023-001)

Significant Deficiency 2023

Oregon Tilth, INC

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting

Oregon Tilth, Inc. respectfully submits the following corrective action plan for the year ending December 31, 2023. Audit: January 1, 2023 to December 31, 2023. The finding from the schedule of findings is discussed below. The finding is numbered with the number assigned in the schedule. FINDING - F...

Oregon Tilth, Inc. respectfully submits the following corrective action plan for the year ending December 31, 2023. Audit: January 1, 2023 to December 31, 2023. The finding from the schedule of findings is discussed below. The finding is numbered with the number assigned in the schedule. FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department Agriculture 2023-001 Market Protection and Promotion – Assistance Lising #10.163 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: The issue with late Federal Funding Accountability and Transparency Act Subaward Reporting was identified by the auditors during the testing and review of documents during our first Single Audit. Management understood the importance of Immediate action and steps were taken to create and implement appropriate procedures, policies and controls. Action Plan: In order to prevent further tardiness with the submission of the obligated sub-recipient funding, a recurring Asana task item was created that reminds the Grant Finance Manager to submit the report 10 days before the end of the month following the obligation of funds. In addition, the Finance & Administration Director has also created a calendar task and reminder to be the stop gap check, and to approve the pdf of submitted reports before the close of the month. An addendum to the Fiscal Policies and Controls guide was sent to the board Finance Committee on Sept. 9th, 2024 that immediately implements the policy and details the oversight procedure for the submission and approval of reports. The sub-recipient FSRS FFATA excel worksheet schedule has been enhanced to include a page that details the month of the award, number of subrecipients and date the report was filed for that month. There is now a self-reporting column that indicates if the report was filed late. And lastly, the Grants Financial Manager has been ordered to insert written procedures into the Grant Internal Controls guide. Name(s) of the contact people responsible for correction action: Renee Kempka, Finance & Administration Director Abigail Soto, Grants Financial Manager Plan completion date for corrective action plan: September 30, 2024

View Audit 320266

Finding 497522 (2023-001)

Significant Deficiency 2023

Na Pu'uwai

HI

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.512

Nā Puʻuwai agrees with the Auditor's advice and as a result, in June of 2024, we began the transition process to our new accounting team, Accumulus, and are confident that moving forward, we will comply fully with timely financial reporting requirements.

View Audit 320264

Finding 497413 (2023-006)

Significant Deficiency 2023

City of Porterville

CA

Reporting Allowable Costs / Cost Principles Cash Management

Staffing for Adequate Fire and Emergency Response (SAFER) - Assistance Listing No. 97.083 Recommendation: It is recommended that SAFER grant reports be reviewed by a supervisory-level person who is not the preparer of the report. Explanation of disagreement with audit finding: There is no disagreeme...

Staffing for Adequate Fire and Emergency Response (SAFER) - Assistance Listing No. 97.083 Recommendation: It is recommended that SAFER grant reports be reviewed by a supervisory-level person who is not the preparer of the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have established a mandatory review process where all reimbursement requests and performance reports must be reviewed and approved by a designated supervisory-level staff member who did not prepare the report before submission to the granter. We have communicated the importance of this review process in ensuring compliance, completeness and accuracy. We will monitor the process to prevent recurrence. Name of the contact person responsible for corrective action: Janie Rodriguez Planned completion date for corrective action plan: August 7, 202

View Audit 320159

Finding 497412 (2023-005)

Significant Deficiency 2023

City of Porterville

CA

Cash Management Significant Deficiency

Staffing for Adequate Fire and Emergency Response (SAFER) - Assistance Listing No. 97.083 Recommendation: It is recommended that SAFER grant reimbursement requests be reviewed by a supervisory-level person who is not the preparer of the requests. Explanation of disagreement with audit finding: There...

Staffing for Adequate Fire and Emergency Response (SAFER) - Assistance Listing No. 97.083 Recommendation: It is recommended that SAFER grant reimbursement requests be reviewed by a supervisory-level person who is not the preparer of the requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have established a mandatory review process where all reimbursement requests must be thoroughly reviewed by a designated finance staff member who did not prepare the request. A final approver (i.e. supervisor or director) will authorize the reimbursement request before submission to the grantor. We have communicated the importance of this review process to our team to ensure compliance, completeness and accuracy. We will monitor the process to prevent recurrence. Name of the contact person responsible for corrective action: Janie Rodriguez Planned completion date for corrective action plan: August 7, 2024

View Audit 320159

Finding 497397 (2023-001)

Significant Deficiency 2023

United States Hispanic Chamber of Commerce

DC

Reporting Significant Deficiency Internal Control / Segregation of Duties

USHCC management has always evaluated the capabilities and resources of the audit firms and their auditors prior to engagement. Unfortunately, USHCC management had no control over internal issues within the audit firm that caused the audit FY2022 reports to be delayed. USHCC management has addressed...

USHCC management has always evaluated the capabilities and resources of the audit firms and their auditors prior to engagement. Unfortunately, USHCC management had no control over internal issues within the audit firm that caused the audit FY2022 reports to be delayed. USHCC management has addressed the issue and contracted with a different firm establishing a timeline and maintaining frequent communication to ensure that the FY2023 reports are submitted in a timely manner.

View Audit 320143

Finding 497395 (2023-001)

Significant Deficiency 2023

Alexandria Borough Water Authority

PA

Internal Control / Segregation of Duties Reporting Significant Deficiency

2023-001 Internal Control over Financial Reporting - Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The small size of the Authority’s office staff does not allow for adequate segregation of duties. Standard practice regarding the design of a good system of internal con...

2023-001 Internal Control over Financial Reporting - Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The small size of the Authority’s office staff does not allow for adequate segregation of duties. Standard practice regarding the design of a good system of internal controls relies at least in part on a system of checks and balances accomplished by having different employees performing various functions within the accounting cycle. These checks and balances are not possible when the same person performs all of an interrelated series of tasks. Although the Authority does have some compensating controls in place, there are still a number of situations where one person is responsible for all aspects of a transaction. Planned Action: The Authority acknowledges the potential effects of this condition. However, for such a small organization as we are, the Authority believes that it would not be cost beneficial to hire additional personnel in order to provide for adequate segregation of duties. As a compensating control, the Board intends to continue its close involvement in, and oversight over, the financial transaction process.

View Audit 320142

Finding 497379 (2023-004)

Significant Deficiency 2023

With Helping Hands Serving Nutritious Meals

TX

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

RE: Finding 2023-004 - Significant Deficiency – Compliance with monitoring response When completing the Monitor Review Reports there are times that the staff completing the documents is busy reviewing, teaching, re-directing the site server while being present at the facility to make use for extra ...

RE: Finding 2023-004 - Significant Deficiency – Compliance with monitoring response When completing the Monitor Review Reports there are times that the staff completing the documents is busy reviewing, teaching, re-directing the site server while being present at the facility to make use for extra training while present. This does not mean that the records should not be taken care of to the standards set forth by TDA. We just sometimes find ourselves in the moment trying to make each site better while we are there monitoring and the records on the monitoring report are missing a few items to complete. The reviewer needs to make sure that the documents of record, Monitor Review is filled out to its entirety at the end of the service time and by the end of the each month when records are turned in and give proper documentation for TDA standards and guidelines. There are times when the records of the Monitor Reviews need to be completed back at the office to ensure the five day reconciliation and meal production records are accurate. At this time the entire Monitor Review packet should be reviewed to ensure it is complete and accurate before turning it into the document binder. See the following step-by-step policy and procedure that is in place effective today Feb. 1, 2024 as these policies were reviewed with staff responsible for these duties. POLICY: Monitor Requirements (Updated Feb 2024) • Being the eyes and ears • Providing valuable feedback about how the sites are operating • Visiting sites on a regular basis and observing the entire meal service • Provide technical assistance to sites and serving staff while present for Monitor Review PROCEDURE: Monitor Review Requirements The monitoring review requirements for facilities participating in the SFSP are as follows: • The Executive Director will conduct a pre-operational visit to every potential site; • The next monitor visit will occur within the first week of operation at each site; and • The minimum number of required visits is 1 within the first 4 weeks of operation, and • A minimum number of required visits is 1 each additional 4 weeks of operation. • If possible due to site approved meal times, he same meal type will not be monitored during each review. • Monitor Review personnel will wear a badge for easy identification. • The Monitor will be present before the meal service begins and stay until the meal service is over. • Sites with findings during the monitor review will be documented and training will be conducted on site. Serious deficiency findings, a monitor review will be conducted within 4 weeks to ensure site is in compliance. If no corrective action is performed, TDA will be notified. • All sites are required to allow access to WHH staff with proper identification and to provide all requested documents that support the Monitor Review. If any site does not comply, the meals will be disallowed for that day and another Monitor Review will be scheduled. • All staff that are responsible for completing Monitor Review’s will attend Monitor Training annually provided by the Executive Director. This training will be given to discuss the importance of the monitor procedures, effective monitor technical assistance given, records completion, findings, training, follow up reviews, serious deficiencies, and procedures set forth by TDA. • All trained monitors will complete the sections of the Monitor Review Documents at the time of the meal service being observed and finish completing the record with the proper documentation back at the office for the Monitor Review Binder. • Each month the trained Monitors will turn in the Monitor Review Documents to the Executive Director for review of completion, status of each site, findings listed, technical assistance given, and for accuracy of the Monitor Review Document. If errors are noted on the Monitor Review Document the Executive Director and Monitor will correct them together to discuss the errors. This will completed at the end of each month before claim submission. The annual monitoring review requirements are based upon the individual facility’s start date in the SFSP.

View Audit 320118

Finding 497378 (2023-003)

Significant Deficiency 2023

With Helping Hands Serving Nutritious Meals

TX

Special Tests & Provisions Significant Deficiency

RE: Finding 2023-003 - Significant Deficiency – Compliance with Resource Management Response On 7/7/23 the office of site King Parkway notified us that the server was not present due to being absent/vacation and another staff member was filling in for the server while they were gone. We immediatel...

RE: Finding 2023-003 - Significant Deficiency – Compliance with Resource Management Response On 7/7/23 the office of site King Parkway notified us that the server was not present due to being absent/vacation and another staff member was filling in for the server while they were gone. We immediately sent over an administrative staff member to train the site “sub” server to ensure the meal service could continue for the kids. There was a TDA representative there doing an unannounced visit at the time. We later found out that the original server of record for King Parkway had Covid and that is why he was absent so abruptly. With this information just given to us only a few minutes before the actual serve time we feel that, we tried to do the best we could by sending over someone to train at the meal service. We understand the ideal situation would be to train this person before the meal service, however there was not enough time to do so. It was brought to our attention that specific day that the site sub, had also been stepping in to help the staff on record to serve on occasions. This information was not given to us until 7/7/23 when the administrative staff was on-site training the site sub. Since this time, the site sub in question has been properly trained and is now the site server of record. The following procedures were updated and put into place effective August 2023. • The Policy & Procedure now includes a new policy for substitutes notification to sponsors when there will be a sub. • Copies of Training Certificate after administrative staff complete training in full on 7/10/2023. POLICY: SFSP Training (Updated Feb 2024) “With Helping Hands” (WHH), its staff and new facility staff who perform key SFSP activities must participate in or receive training in the following areas and subtopics: • Program Meal Pattern o Child meal pattern o Serving sizes for age groups o Creditable foods o Meal service styles o Accommodating special needs diets o Menu planning • Meal Counts o Daily o Weekly o Monthly • Claims Submission o Due date o Late claims o Amended claims • Claims Review Procedures o Review elements o Adverse Action o Appeal rights • Recordkeeping Requirements o Daily, weekly, monthly forms o Child Nutrition Program Application o Annual enrollment information o Meal production records o Attendance records o Financial Records o Record retention o Purchase vended meals • Reimbursement System o Administrative fee o Payment schedule • Civil Rights • Site Substitutes • Site Closures PROCEDURE: (Updated Feb 2024) 1. TDA may require “With Helping Hands” Management to attend additional training during the program year. The TDA will notify WHH when [mandatory] training is scheduled for Executive Directors/Management. 2. WHH Executive Director(s) train all new sites on SFSP during the New Site Pre-Approval Visit. 3. Site Supervisors are responsible for training their site staff prior to performing any SFSP activities. WHH provides all training documents and offers training and technical assistance to all sites and their staff as needed or requested. If found during Monitoring Review that any staff performing SFSP activities has not completed the annual SFSP training or needs further training based on findings, Monitor will conduct training on site. 4. WHH Management will ensure training of all employees will be provided annually on the SFSP program as noted in the policy statement above. Annual training topics will be discussed but will be tailored to each individual specific to their job responsibilities. 5. Civil rights training is a self-paced training curriculum provided online by TDA. It can be accessed from the TDA website at www.squaremeals.org (instructions are included in training packet). All individuals who have SFSP responsibilities must complete this training annually. Office Tech/Clerical Staff ensure that Civil Rights has been completed by comparing Time Distributions to Civil Rights documentation monthly. If it is found during a Monitoring Review that a staff performing key SFSP activities has not completed Civil Rights Training, site supervisors will be notified and staff will be removed from duties until training is complete. 6. WHH Management will ensure training of all employees that serve or handle food will be trained properly and receive training prior to the start of any meal service in which they are participating in. This training can be done on-line or in person provided by the sponsor before the server begins any meal service. Administrative Staff will monitor all sites to ensure the server of record are properly trained and the ones providing services at the approved meal service. 7. Site Supervisors will notify the Site Manager or Sponsor if they can not be present for meal service, if anyone else will be responsible to serve the meal, and only allow the site substitute to serve the meal if they have completed training prior to serving the meal. If a trained substitute can not be present for the meal service then the meal service will be cancelled for the day. Site Supervisor must notify the Sponsor immediately. 8. Signed receipt of training will be kept on file by WHH management in a training folder and maintained for 4 years.

View Audit 320118

Finding 497377 (2023-002)

Significant Deficiency 2023

With Helping Hands Serving Nutritious Meals

TX

Reporting Significant Deficiency

RE: Finding 2023-002 – Significant Deficiency – Compliance with Accurate Records of Meal Preparation and Ordering Response During the TDA audit, the CE provided meal production records as supporting documentation for meal preparation. Although the meal production record shows the number of meals pre...

RE: Finding 2023-002 – Significant Deficiency – Compliance with Accurate Records of Meal Preparation and Ordering Response During the TDA audit, the CE provided meal production records as supporting documentation for meal preparation. Although the meal production record shows the number of meals prepared, the quantity prepared is insufficient for the number of participants the sites anticipate serving per the Food Buying Guide. The meal Production record dated 07/07/2023, shows that the central kitchen prepared 40 lunches for a site. Per the meal production record, the kitchen used 2 #10 cans of sliced peaches to prepare 40 meals, which is not enough to ensure that 40 participants received the correct quantity. Meal Production Records are prepared daily and presented to the kitchen staff in preparation for the meal service. All calculations are done using the food-buying guide on www.squaremeals.org. It was brought to our attention that there were a few calculations that were off on the meal production sheet at the time of the Review. The circumstances that caused this error was simply wrong human calculations that needed to be reviewed by additional staff to ensure the errors were corrected. We pride ourselves in knowing our kids we serve receive quality meals and enough meals are prepared to ensure all children receive the proper quantities. A. To ensure any calculation error does not occur the following steps, process and procedures were updated and implemented effective December 2023 after receiving additional training from Region IV ESC when three staff members attended Meal Production Records training—4 hours. B. Training certificates for the three staff members that attended Meal Production Records training were provided to TDA. Although the training was for CACFP, the process and results are the same for SFSP. This was the most recent training provided and we attended it in order to make the appropriate changes necessary for our program. POLICY: Daily Meal Production (Updated Nov 2023) “With Helping Hands” (WHH) must ensure that its central kitchen and sponsored facilities prepare a meal production record for each meal service each day. The center/facility (ies) must record the food items used, and quantities on a daily basis on H1530, Daily Meal Production Record, or H1530-A. PROCEDURE: All SFSP Program meals prepared by WHH will follow the TDA standard/established guidelines for proper meal pattern servings. Form H1530, Daily Meal Production Record will be completed prior to meal preparation as follows for reimbursement under the SFSP Program. 1) All areas of the form (listed below) need to be completed in entirety: a) Name of contractor b) Name of facility (only required for multiple facilities or if the facility name differs from contractor) c) Agreement number (this is the same as the TX number) d) Dates covered e) Day of meal service f) Food components g) Menu(s) h) Food items used i) Quantity used j) CN Labels used k) Special Diets l) USDA Recipe Numbers m) Whole grains n) Planned participation program meals o) Planned participation non-program meals 2) Meal Calculations are completed by the office staff using the food-buying guide via www.squaremeals.org. These calculations will be verified and checked at random within the month from Administrative Staff to ensure the accuracy of the calculations. 3) The Administrative Staff will check Meal Productions at the end of each week to ensure accuracy and completion. 4) Meal production records must be completed by office and kitchen staff on a daily basis and submitted to the Administrative Staff by the 5th of every month for processing the claim. 5) If there are any findings such as: a. Missing components b. Unallowable food items c. Not enough food prepared d. Uncompleted or Missing Completely e. Wrong Calculations Staff will be given corrective action and review of policy and procedures will be enforced by the Executive Director. 6) If more findings occur, Production Record training will be conducted on-site or via web. 7) Meal Production Training will be taken annually by the Region IV ESC Center annual training INSPO or other training options offered by the ESC and/or TDA SFSP Training Sessions.

View Audit 320118

Finding 497376 (2023-001)

Significant Deficiency 2023

With Helping Hands Serving Nutritious Meals

TX

Questioned Costs Reporting Significant Deficiency

RE: Finding 2023-001 – Significant Deficiency – Compliance with Daily Meal Count Records not Being Accurately Completed Response The meal count on 7/14/23 and 7/21/23 for King Parkway Mobile Home was incorrect as the server just wrote down the number of meals served and did not circle the numbers a...

RE: Finding 2023-001 – Significant Deficiency – Compliance with Daily Meal Count Records not Being Accurately Completed Response The meal count on 7/14/23 and 7/21/23 for King Parkway Mobile Home was incorrect as the server just wrote down the number of meals served and did not circle the numbers as instructed. This was just a careless error on the server’s part and further training on point of service was needed. The other error on the meal count records was the server indicated 20 meals were served but forgot to circle the very first number on the sheet, therefore there were only 19 numbers circled for the claim. The staff member that was adding the meal count consolidation form perhaps looked at the delivery ticket and not the meal count form to record the number of meals. This too is something that has been addressed and more training was needed. To ensure the Meal Count does not have any errors the Policy & Procedures have been updated as follows: POLICY: Daily Meal Count and Attendance Record (Updated Feb 24) As per TDA Guidelines, a CE must record meal counts and attendance on a daily basis. A CE must record meal counts at the point of service where their staff observe that an eligible child receives a creditable meal. A meal is creditable when a child receives all required components in the correct quantities at the approved mealtime. Daily Meal Count and Attendance Records must be completed at the point of service. POLICY: Meal Service Consolidation (Updated Feb 2024) As per TDA Guidelines each meal must be reported individually. SFSP sites may claim breakfast and supper served to children on week days, weekends, and holidays during a school's summer session. PROCEDURE: “With Helping Hands” (WHH) staff will report each meal separately on the daily meal count form and on a monthly meal consolidation form. The following conditions also apply to the meal service schedule: • The duration of a meal service must not exceed 1 ½ hours for breakfast and 2 hours for supper; • Any meals served outside of the approved meal times will not be claimed or they will be disallowed. • All meals will be recorded at the point of service by the Site Supervisor. • Each site will have their weekly totals and monthly totals reported on the monthly meal consolidation form. • Meal Count Forms will be turned in weekly from the Site Supervisor to the office for processing the claim submission. The office staff and Executive Director will review all documentation prior to claim submission. • Meal Count Consolidation Form will be completed and checked by two staff members’, including the Executive Director. • If the meal count sheet does not match the delivery ticket or any item is missing from the meal count sheet form the meal will be disallowed and further training will be done immediately with the site supervisor and/or staff at that location. • A claim will only be submitted for the meals that are supported by all complete and required documentation.

View Audit 320118 Questioned Costs: $1

Finding 497353 (2023-006)

Significant Deficiency 2023

The Well Community Development Corporation

OH

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting

Invoices and receipts submitted by the Housing Team to the Business Manager will include the grant name to avoid any confusion as to the proper allocation to the federal funding source.

View Audit 320076

Finding 497348 (2023-004)

Significant Deficiency 2023

Waushara County

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

WIMCR Reporting Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accur...

WIMCR Reporting Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and sign-off needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan will be in place for 2023 reporting during 2024.

View Audit 320071

Finding 497346 (2023-005)

Significant Deficiency 2023

Town of Paradise

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Finding Reference Number: 2023-005 Description of Finding: The expenditure information provided to report the amounts of the SEFA contained totals representing transfers from other funds instead of individual expenditure amounts. Statement of Concurrence or Nonconcurrence: Financial ...

Finding Reference Number: 2023-005 Description of Finding: The expenditure information provided to report the amounts of the SEFA contained totals representing transfers from other funds instead of individual expenditure amounts. Statement of Concurrence or Nonconcurrence: Financial information contained large transfers for projects that crossed multiple funds and funding sources. Corrective Action: During FY23/24 the town implemented individual expenditure detail for federal awards expenditures in the general ledger and supplemental listings. Invoices and payroll are direct billed to projects contained within the project’s fund. The town now only transfers minimally as needed for overhead type of transactions. Name of Contact Person: Aimee Beleu, Finance Director, (530) 872-6291, abeleu@townofparadise.com Projected Completion Date: 4/1/2024

View Audit 320057

Finding 497337 (2023-001)

Significant Deficiency 2023

Rochester Area Joint Sewer Authority

PA

Internal Control / Segregation of Duties Cash Management Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: We will continue segregating duties among the Authority Manager, Board, and Accounting Manager. An individual other than the Accounting Manager will review cancelled checks to ensure payment amount and payee agreed with what was approved...

Views of Responsible Officials and Planned Corrective Actions: We will continue segregating duties among the Authority Manager, Board, and Accounting Manager. An individual other than the Accounting Manager will review cancelled checks to ensure payment amount and payee agreed with what was approved by the board. In late 2023, the Office Manager and Accounting Manager decided to leave their current role to pursue other opportunities. The Authority Manager acted swiftly to fill those positions with the hiring of a new Office Manager and Accounting Manager in August 2023 and October 2023, respectively. Both new employees are being trained on the accounting processes to allow for 1.) redundancy in personnel and 2.) assist in improving controls specific to the segregation of duties for recordkeeping, custody, and authorization. The Authority follows the following federal award reimbursements requests and payment approval process: Federal Award Reimbursement & Contractor Payment: 1. A licensed independent Engineer detail reviews all invoices/pay applications and signs and certifies the work completed before providing to the Authority. 2. After the Engineer approves invoices/pay applications, they are sent to the Office Manager who begins data entry into PENNVEST’s online request portal. The Office Manager then prepares the payment request packets for the upcoming board meeting and QuickBooks entries for federal award tracking. 3. The Board reviews the submittal packets in detail and provides approval to submit the request for reimbursement to PENNVEST. 4. After Board approval, the Accounting Manager submits the request and corresponding invoice/pay application support to PENNVEST’s online portal. 5. PENNVEST reviews the request for disbursements. Once approved, they wire funds to the Authority’s bank account. 6. After the Authority receives the funds from PENNVEST, they begin the process to pay the Contractors. 7. Payment to contractors occurs through written check or ACH after approval and at minimum two signatures are obtained from the Board and the Authority Manager. All paper checks require two signatures. ACH payments to contractors require a board member approval in the form of a signature on the ACH printout prepared by the Accounting Manager. 8. The Office Manager performs the bank reconciliation process within QuickBooks and clears any outstanding checks on the reconciliation module. 9. The Accounting Manager reviews the bank statement reconciliation and any outstanding account payables.

View Audit 320046

Finding 497334 (2023-001)

Significant Deficiency 2023

Savio House

CO

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Planned Corrective Action: Savio believes that our internal control system is effective in determining allowable costs charged to the grant. In addition to the reviews done by the Controller, there is an additional third party review to ensure all costs are allowable. We do believe that we could bet...

Planned Corrective Action: Savio believes that our internal control system is effective in determining allowable costs charged to the grant. In addition to the reviews done by the Controller, there is an additional third party review to ensure all costs are allowable. We do believe that we could better segregate the controls within the Organization to further improve the system of internal controls. We will modify our controls to require that all expenses along with the indirect rate and calculation will be reviewed and approved by the Development department rather than the controller to provide a better review process for appropriateness and support of costs before reimbursement, as recommended by the auditor. Since the Development department writes the grants they would have the best knowledge on what expenses qualify and verify support. This will be implemented immediately. Name of Contact Person: Eric Heppe, Controller, EHeppe@saviohouse.org Anticipated completion date: September 2024 invoicing process

View Audit 320032

Corrective Action Plans

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