Corrective Action Plans

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Condition: During testing of 40 sampled cases, 1 case was identified where aid code 30 was charged after the 60-month lifetime limit. The noncompliant payments occurred in December 2024, January 2025, and February 2025, totaling $2,652. Recommendation: CLA recommends the County strengthen monitoring...
Condition: During testing of 40 sampled cases, 1 case was identified where aid code 30 was charged after the 60-month lifetime limit. The noncompliant payments occurred in December 2024, January 2025, and February 2025, totaling $2,652. Recommendation: CLA recommends the County strengthen monitoring controls to ensure benefits are terminated promptly upon reaching the 60-month limit unless valid exemptions are documented, implement periodic system audits to detect and prevent similar errors, provide staff training on proper coding and documentation for exemptions such as aid code 33 for hardship or extreme cruelty, and recover improper payments where feasible while reporting corrective actions to the State Department of Social Services. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective action plan: Implement Standardized Controls to ensure time limit review and transition at 60 months. Department will operationalize the use of monthly ad-hoc reporting within CalSAWS to identify individuals approaching 60 months and confirm tasks set for follow-up: Name(s) of the contact person(s) responsible for corrective action: Rachel Ebel-Elliott, Social Services Deputy Director Planned completion date for corrective action plan: 6/30/2026
Finding Number: 2025-002 – Special Tests and Provisions – Gramm Leach Bliley Act Missing Compliance Requirements Auditor Description of Condition and Effect: The Gramm Leach Bliley Policy, in effect at time of audit, failed to explicitly state how the university addressed the implementation of multi...
Finding Number: 2025-002 – Special Tests and Provisions – Gramm Leach Bliley Act Missing Compliance Requirements Auditor Description of Condition and Effect: The Gramm Leach Bliley Policy, in effect at time of audit, failed to explicitly state how the university addressed the implementation of multi-factor authentication for anyone accessing customer information on the institution's system, conducting a periodic inventory of data that notes where it is collected, stored, or transmitted, encrypting customer information on the institution's system and when it's in transit, and anticipating and evaluating changes to the information system or network. The University did not have a review process in place for ensuring all required safeguard were written in the information security program in accordance with the Gramm Leach Bliley Act. Auditor Recommendation: We recommend that the University implement procedures to ensure that all Gramm Leach Bliley policies are met and verified by a second individual. Views of Responsible Officials and Planned Corrective Action: Beginning in fiscal year 2026, Office of Information Technology (OIT) implemented an updated policy/procedure aligned with the Gramm Leach Bliley Act (GLBA) Information Security Program requirements. The updates include: implementation of multi-factor authentication (MFA) for anyone accessing customer information on the institution's system; conducting a periodic inventory to identify where customer information is collected, stored, or transmitted; encryption of customer information both on institutional systems and during transmission; procedures to anticipate and evaluate changes to the information system or network that may impact data security. Although not fully documented, the following measures were already implemented and operational at the time of audit: Multi-Factor Authentication (MFA): MFA has been in place for all systems that access customer financial information, in accordance with FTC Safeguards Rule updates effective June 2023; Encryption: Both data at rest and in transit have been encrypted using industry-standard protocols, consistent with GLBA requirements; and Data Inventory: A periodic inventory of systems and data flows has been conducted, identifying where customer information is collected, stored, and transmitted. This is part of our broader risk assessment and information security program. Internal Audit reviewed the policy and associated processes against the applicable regulation (16 CFR 314) and concluded that we were in compliance based on the regulatory guidance available. It was not until the release of the final 2025 Compliance Supplement in late November 2025 that clarification was provided indication that all eight minimum safeguards must be explicitly documented within the written information security program. Additionally, the University has established a formal review process to ensure all GLBA safeguard policies are met. Key personnel and leadership within OIT will conduct regular compliance reviews to verify adherence and promote operational efficiency. Contact person responsible for corrective action: Jerry Todd, Chief Information Security Officer, Office of Information Technology Information Security Anticipated Completion Date: 12/1/2025
Finding Number: 2025-001 – Special Tests and Provisions - Enrollment Reporting Auditor Description of Condition and Effect: In our testing of eighteen students, we noted two students who were reported with inaccurate effective dates. The University's reporting process relies on SAP system data for N...
Finding Number: 2025-001 – Special Tests and Provisions - Enrollment Reporting Auditor Description of Condition and Effect: In our testing of eighteen students, we noted two students who were reported with inaccurate effective dates. The University's reporting process relies on SAP system data for NSLDS reporting, which did not accurately reflect the student’s actual last date of attendance. Auditor Recommendation: We recommend that the University enhance its policies and procedures regarding enrollment reporting to ensure that reporting is completed accurately. Views of Responsible Officials and Planned Corrective Action: Effective immediately following the Office of Technology system updates, the Registrar’s Office and Student Account Services and University Billing (SASUB) will begin utilizing SAP to store R2T4 dates. These dates will automatically populate the monthly National Student Clearinghouse (NSC) enrollment files, improve reporting accuracy, compliance, and the management of withdrawn students. This centralized platform provides authorized users with streamlined access to view pending returns, associated deadlines, and completion dates for each case. The system enhances tracking accuracy, strengthens accountability, and promotes transparency and communication among university stakeholders. Key personnel and leadership from the Registrar’s Office and SASUB will conduct regular reviews to ensure compliance and operational efficiency. Contact person responsible for corrective action: Keith J. Malkowski, Registrar of Registrar’s Office & Brian C. Bell, Director of Student Account Services and University Billing Anticipated Completion Date: 2/28/2026
Views of Responsible Officials and Corrective Action Plan Responsible Officials: Associate Dean, Financial Aid & Scholarships, Director of Financial Aid & Scholarships Enhanced data on source reports The Associate Dean of Financial Aid & Scholarships, Director of Financial Aid & Scholarships, and Sy...
Views of Responsible Officials and Corrective Action Plan Responsible Officials: Associate Dean, Financial Aid & Scholarships, Director of Financial Aid & Scholarships Enhanced data on source reports The Associate Dean of Financial Aid & Scholarships, Director of Financial Aid & Scholarships, and System Specialist worked with the MIS (IT) Department to enhance information provided on the reports used by Financial Aid staff to facilitate identifying student withdrawals and initiating the calculation process. Enhanced report will cut down on the need to manually check student information as the Specialist is processing students. New data elements on the report include course and class section information, start and end week, number of units by course, drop date field and the instructor e-mail. Increase frequency of generating the student withdrawal report. The System Specialist has scheduled on their calendar to run the student withdrawal report every week to ensure that the withdrawals are identified in a timely manner and the calculations and returns are completed within the 45-day window. Redistributed department workload; Specialist focused on withdrawal determination/calculation. The Associate Dean has tasked additional office support to assist the System Specialist in the communication follow up with the impacted students, freeing up the System Specialist’s workload to concentrate fully on the withdrawal determination and calculation completion. Monthly review by Associate Dean to confirm adjustments completed for student withdrawals. The Associate Dean will request a monthly report to review and ensure that the calculations and aid adjustments are completed for each student who has withdrawn. This process update will put in place internal checks and balances over the review of the calculations to ensure financial aid funding is returned in a timely manner. The Associate Dean, or their designee, will sign-off that they have reviewed the report each month and file a copy.
Corrective Action: An unnecessary step in the process was removed . Previously, program staff waited for funder confirmation approving the billing report before attaching a screenshot and submitting the executive summary. The process has been updated, so screenshots are submitted without waiting for...
Corrective Action: An unnecessary step in the process was removed . Previously, program staff waited for funder confirmation approving the billing report before attaching a screenshot and submitting the executive summary. The process has been updated, so screenshots are submitted without waiting for funder approval. In addition, the accounting department will shift its closing date 1 day prior to the funder's executive summary reporting deadline. Responsible Parties: Chief Program Officer & Chief Financial Officer Date to be Corrected: 03/31/2026 If the U.S. Department of Labor has any questions regarding this plan, please contact Liliana Rambo, CEO, 713.773.6000 x 117.
National Student Loan Data System (NSLDS) Recommendation: We recommend reviewing the components of the enrollment roster file to ensure the correct effective date is reported correctly for the "Campus Level" as well as making sure records are being timely reported. Explanation of disagreement with a...
National Student Loan Data System (NSLDS) Recommendation: We recommend reviewing the components of the enrollment roster file to ensure the correct effective date is reported correctly for the "Campus Level" as well as making sure records are being timely reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Although the Colleague data is correct, the logic in Colleague used to send the files to the NSC is excluding records when the student is not registered for classes in the month an action such as graduation or withdrawal occurs. In that situation the NSC is inserting default dates onto the record based on the last date of their classes in the prior term. We will continue to manually review and correct issues when needed. Name of the contact person responsible for corrective action: Sean Murphy, Registrar Planned completion date for corrective action plan: Already in place.
Views of Responsible Officials and Corrective Action Plan We concur. Management has revised its procedures for R2T4, as well as added additional monthly review to ensure compliance.
Views of Responsible Officials and Corrective Action Plan We concur. Management has revised its procedures for R2T4, as well as added additional monthly review to ensure compliance.
Americorps Seniors Senior Companion Program – Assistance Listing No. 94.016 Recommendation: We recommend that additional review procedures are put in place to ensure the volunteer type is accurate based on their income review. Explanation of disagreement with audit finding: There is no disagreement ...
Americorps Seniors Senior Companion Program – Assistance Listing No. 94.016 Recommendation: We recommend that additional review procedures are put in place to ensure the volunteer type is accurate based on their income review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program leadership will review and update existing policies and procedure manuals to ensure provide clear and accurate steps to adhere to funding guidance. The supporting technology will be updated in a manner that will require program coordinators/managers to actively complete a required field to verify current income eligibility. In addition, the program will develop and implement an active review process to monitor and support compliance and accurate record keeping. Name(s) of the contact person(s) responsible for corrective action: Drew Erickson Planned completion date for corrective action plan: 02/28/2026
2025-008 Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College provide all necessary employees with training, support, and sufficient time to follow College policies and federal requirements related to monthly reconciliations. Explanation of disagreem...
2025-008 Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College provide all necessary employees with training, support, and sufficient time to follow College policies and federal requirements related to monthly reconciliations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College utilizes a third party service provider to service both the Nurse Student and Nurse Faculty Loan programs. Due to staff turnover and the student information system implementation of Anthology, there was inconcistency in what was has been provided for both loan programs. As of FY 2025 year-end and looking forward, the College finance team has taken the additional steps to review and reconcile the balances. In the review, it was noted that there was an issue with the uploading of date to the third party provider and the College has added additional controls in a review of data that is received by the provider as well as regular communication between the College Finance department and Financial Aid departments on any discrepencies. Name(s) of the contact person(s) responsible for corrective action: Nathan Wiegand, VP of College Finance/CFO Planned completion date for corrective action plan: Implemented in FY 2026.
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College review and strengthen its policies and procedures to ensure that all student credit balances resulting from federal funds are refunded within the required 14-day period. Explanation of disagreement...
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College review and strengthen its policies and procedures to ensure that all student credit balances resulting from federal funds are refunded within the required 14-day period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This finding was from Fall of 2024. During the Fall semester of FY 25, Clarkson College experienced turnover with its financial aid department staff. From Spring 2025 on, the financial aid department now processes financial aid weekly on Monday through Wednesday each week. The student accounts team in turn runs a report for any credit balances on Thursday morning each week. Upon running the report, the student accounts team will then process and issue either a check or ACH payment refund that same day so that at most, there is a eight-day period. In addition, the College enhanced the check payment process so that the checks can be generated, printed, and mailed same-day. Name(s) of the contact person(s) responsible for corrective action: Nathan Wiegand, VP of College Finance/CFO Planned completion date for corrective action plan: Implemented in January, 2025.
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College establish a process to ensure that all disbursement information is accurately reported to the COD system. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College establish a process to ensure that all disbursement information is accurately reported to the COD system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: It was noted in COD that a disbursement date did not match the date recorded in our Anthology system; the discrepancy was by one day. Once identified, the Financial Aid team corrected the error. Unfortunately, the correction was made outside the required 15-day window. All disbursement dates have now been updated, and we have implemented a new process to ensure that all dates in Anthology and COD align. The Financial Aid team is actively monitoring this to ensure that current and future disbursement dates consistently match providing an additional reconciliation of dates. Name(s) of the contact person(s) responsible for corrective action: Dr. Carla Dirkshneider, VP of Enrollment and Retention Planned completion date for corrective action plan: Implemented
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College implement a review process that compares enrolled credits to Pell awards to ensure all students receive the correct Pell Grant amounts. Explanation of disagreement with audit finding: There is no d...
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College implement a review process that compares enrolled credits to Pell awards to ensure all students receive the correct Pell Grant amounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: There was one student in Fall 2024 who was under-awarded Pell Grant funds due to an error related to the student’s withdrawal status and the number of credits attempted. The Pell award was manually processed incorrectly based on this enrollment change. Beginning in Spring 2025, the Financial Aid team implemented a new process requiring a formal review of enrollment intensity for all students prior to determining and disbursing Pell Grant funds. This ensures that Pell awards are calculated and adjusted accurately. Additionally, the team now utilizes enrollment and Pell related reports to help identify potential changes in student enrollment and support timely, accurate award reviews. Name(s) of the contact person(s) responsible for corrective action: Dr. Carla Dirkshneider, VP of Enrollment and Retention Planned completion date for corrective action plan: Corrective action was implemented January, 2025.
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend the College review the R2T4 requirements and implement procedures to ensure that calculations use the correct number of break days and are completed accurately and within the required timeframes. Explanation ...
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend the College review the R2T4 requirements and implement procedures to ensure that calculations use the correct number of break days and are completed accurately and within the required timeframes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the review period, two students did not receive their Return to Title IV (R2T4) calculations within the required 45-day timeframe. The delay occurred because the Financial Aid Office did not receive the corresponding change of registration forms from the Registrar’s Office, which is necessary to initiate the R2T4 process. To prevent recurrence, the Financial Aid Office has implemented the following corrective actions: 1. Monitoring Reports: The team now runs a student status change report to independently identify potential R2T4 cases, even if documentation has not yet been forwarded. 2. Improved Communication Workflow: Financial Aid has been added to the Registrar’s change of registration email distribution list to ensure timely notification of withdrawals, drops, and status changes. These measures strengthen internal controls, improve cross departmental communication, and ensure that all future R2T4 calculations are completed within federal timelines. Name(s) of the contact person(s) responsible for corrective action: Dr. Carla Dirkshneider, VP of Enrollment and Retention Planned completion date for corrective action plan: Corrective action was implemented in June 2025.
Recommendation: CLA recommends the Agency follow its prescribed policy of supervisors performing and documenting their approval of the documentation of employees' time and effort. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to ...
Recommendation: CLA recommends the Agency follow its prescribed policy of supervisors performing and documenting their approval of the documentation of employees' time and effort. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: We have revised our policy and procedures to make sure that all employees and supervisors are required to approve their timesheet and a follow-up from our HR department will ensure that we have established compliance with this finding. Name of the contact person responsible for corrective action: Dhiren Shah, CFO Planned completion date for corrective action plan: Immediately
Recommendation: CLA recommends the Agency update its procurement policy to include procedures that a vendor be verified as not being debarred, suspended, or excluded and documentation maintained to support the determination. Explanation of disagreement with audit finding: There is no disagreement wi...
Recommendation: CLA recommends the Agency update its procurement policy to include procedures that a vendor be verified as not being debarred, suspended, or excluded and documentation maintained to support the determination. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Agency is committed to following the procurement process and requirements outlined within the policies and procedures. The Agency plans to revise current procurement policy to have a process for debarred, suspended, or excluded and documentation maintained to support the determination. All procurement will be monitored through the Sage Intacct and Ramp system, which has already been implemented. Name of the contact person responsible for corrective action: Dhiren Shah, CFO Planned completion date for corrective action plan: Immediately
Recommendation: CLA recommends the Agency maintain an audit trail for all procurements. This can be done electronically for efficiency. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Agency is committed to followin...
Recommendation: CLA recommends the Agency maintain an audit trail for all procurements. This can be done electronically for efficiency. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Agency is committed to following the procurement process and requirements outlined within the policies and procedures. The Agency plans to revise current procurement policy to have a process for the maintenance of documentation related to procurement determinations. All procurement will be monitored through the Sage Intacct and Ramp system, which has already been implemented. Name of the contact person responsible for corrective action: Dhiren Shah, CFO Planned completion date for corrective action plan: Immediately
Management agrees with the finding. Management plans to implement a process to ensure that the AMR report will be submitted accurately. If the Federal Audit Clearinghouse has questions regarding this plan, please call Cindy Donaldson, Director of Finance, at 540-635-7141.
Management agrees with the finding. Management plans to implement a process to ensure that the AMR report will be submitted accurately. If the Federal Audit Clearinghouse has questions regarding this plan, please call Cindy Donaldson, Director of Finance, at 540-635-7141.
The NSWSD Board will include motions and votes pertaining to the approval of federal funding requests in their Meeting Minutes to ensure all Uniform Guidance regulations, relating to allowability, accuracy, and proper authorization of federal expenditure requests, are performed in accordance with fe...
The NSWSD Board will include motions and votes pertaining to the approval of federal funding requests in their Meeting Minutes to ensure all Uniform Guidance regulations, relating to allowability, accuracy, and proper authorization of federal expenditure requests, are performed in accordance with federal regulations.
The District has reviewed the policies and procedures over the R2T4 calculation and has identified additional controls to prevent miscalculations going forward. The Student Financial Aid Office has begun the implementation of the following corrective action plan to prevent future recurrence: Impleme...
The District has reviewed the policies and procedures over the R2T4 calculation and has identified additional controls to prevent miscalculations going forward. The Student Financial Aid Office has begun the implementation of the following corrective action plan to prevent future recurrence: Implement a cross-check with the Common Origination & Disbursement (COD) site R2T4 calculator to supplement the tools within our internal financial system. The COD system automatically calculates dates attended by students, eliminating the manual element of this step in the calculation. Implement a second review to spot check calculations during each semester to ensure accuracy. Require Blue Icon R2T4 training and certification for staff preparing, reviewing, and processing R2T4 calculations. These controls began implementation in November 2025 and are expected to be fully in place by March 2026. New regulations for R2T4 are expected to be released in early 2026. Blue Icon training will be scheduled once the new regulations are released.
Health Resources and Services Administration Health West, Inc. respectfully submits the following corrective action plan for the year ended May 31, 2025. Audit period: June 01, 2024 - May 31, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are n...
Health Resources and Services Administration Health West, Inc. respectfully submits the following corrective action plan for the year ended May 31, 2025. Audit period: June 01, 2024 - May 31, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT There were no findings in the current year. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2025-001 Health Center Program Cluster – Assistance Listing 93.224/93.527 Recommendation: CLA recommends implementation of an enhanced review process prior to UDS submission. Action taken in response to finding: Health West will implement a dual review process prior to the UDS submission. Name of the contact person responsible: Melissa Myers, CFO Planned completion date: Health West will make this effective for the 2025 UDS report. If the Health Resources and Services Administration has questions regarding this plan, please call Melissa Myers, CFO at (208) 232-7862.
Corrective Action Plan 2025-001: We acknowledge the overaward of Direct Subsidized Loans and underaward of Unsubsidized Loans for both students identified in the finding. Based on the guidance in Volume 8, Chapter 3 of the 2024-2025 Federal Student Aid Handbook which states “If you discover that a s...
Corrective Action Plan 2025-001: We acknowledge the overaward of Direct Subsidized Loans and underaward of Unsubsidized Loans for both students identified in the finding. Based on the guidance in Volume 8, Chapter 3 of the 2024-2025 Federal Student Aid Handbook which states “If you discover that a student received Direct Subsidized Loan funds in excess of financial need after the student is no longer enrolled for the loan period, you are not required to take any action to eliminate the excess subsidized loan amount.” We have not adjusted the student’s loan awards given the identification of the overaward took place after the end of the loan period for each student. As the University has closed after August 15, 2025, no additional actions are considered necessary. Completion Date: August 2025 Contact Person: Ann Spall, Chief Financial Officer
SA-2025-01 - SIGNIFICANT DEFICIENCY FINDING: During our testing of Title 1 disbursements, we noted there were multiple purchases shipped directly to a private residence without receipt of the products at the District office. All disbursements should be shipped to District property for accountability...
SA-2025-01 - SIGNIFICANT DEFICIENCY FINDING: During our testing of Title 1 disbursements, we noted there were multiple purchases shipped directly to a private residence without receipt of the products at the District office. All disbursements should be shipped to District property for accountability, tracking and ensuring compliance with federal regulations. When supplies are shipped to private residences, there exists the increased likelihood of errors and fraud. AUDITOR RECOMMENDATION: We recommend all disbursements be shipped to District property. PLAN OF ACTION AND TIMEFRAME FOR IMPLEMENTATION: The district acknowledges the finding and has already met with the Title 1 Coordinator and the District purchasing clerk immediately after the exit meeting with the auditors to ensure this does not occur again effective this 2025-2026 school year.
Section 223(f) Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects – Assistance Listing No. 14.155 Recommendation: The Project should ensure that all inspection reports are signed by the housing manager and the tenant. Explanation of disagreement with audit find...
Section 223(f) Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects – Assistance Listing No. 14.155 Recommendation: The Project should ensure that all inspection reports are signed by the housing manager and the tenant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met. Name(s) of the contact person(s) responsible for corrective action: Carol Borgerson, CFO Planned completion date for corrective action plan: December 3, 2025
Management concurs with Audit Finding 2025-004 and will strengthen controls over USDA commodity receiving documentation and related reporting to ensure compliance with Food Distribution Cluster special tests and provisions and reporting requirements. Management will implement the following correctiv...
Management concurs with Audit Finding 2025-004 and will strengthen controls over USDA commodity receiving documentation and related reporting to ensure compliance with Food Distribution Cluster special tests and provisions and reporting requirements. Management will implement the following corrective actions: 1. Required Receiving Worksheets for USDA Commodity Receipts Management will reinforce the requirement that a completed receiving worksheet be prepared for all TDA USDA commodity receipts. Each receiving worksheet will be signed or initialed by the receiving employee at the time of receipt to evidence verification of quantities received. 2. Reconciliation of Receiving Documentation to CERES Management will implement a formal reconciliation process to ensure all USDA receiving documentation is reconciled to CERES inventory entries prior to submission of monthly TEFAP reports. Any discrepancies will be promptly investigated, resolved, and documented. 3. Supervisory Review and Approval Supervisory personnel will perform periodic documented reviews to verify that: o All USDA commodity receipts are supported by completed and signed receiving worksheets; and o Receiving activity is accurately and completely recorded in CERES. Evidence of supervisory review will be retained. 4. Documentation Retention and Standardization All receiving worksheets and supporting documentation will be retained in accordance with Food Distribution Cluster record retention requirements. Management will standardize receiving forms and procedures to promote consistency and completeness. 5. Training and Ongoing Monitoring Management will provide refresher training to warehouse and inventory staff on USDA receiving requirements and the importance of timely, accurate documentation. Management will periodically monitor compliance with these procedures to ensure controls are operating effectively. Expected Completion Date: Within 60–90 days Responsible Parties: Donavann Brooks, Inventory Control Manager (901-527-0422)
Management concurs with Audit Finding 2025-003 and will strengthen controls over USDA Food Distribution Cluster reporting to ensure accuracy, completeness, and compliance with federal and State requirements. Management will implement the following corrective actions: 1. Monthly USDA Reporting Reconc...
Management concurs with Audit Finding 2025-003 and will strengthen controls over USDA Food Distribution Cluster reporting to ensure accuracy, completeness, and compliance with federal and State requirements. Management will implement the following corrective actions: 1. Monthly USDA Reporting Reconciliation Process Management will implement a formal monthly reconciliation process that includes: o Reviewing confirmed USDA receipts and reconciling them to internal inventory records in CERES; and o Reconciling all TEFAP distribution reports submitted to the States to CERES data prior to submission. All reconciliations will be documented, reviewed, and retained. 2. Documentation of Shortages and Inventory Adjustments Shortages noted on signed agency invoices will be promptly documented and resolved through credit memos or inventory adjustments in CERES. Supporting documentation will be retained to substantiate all adjustments. 3. 48-Hour Receipt Confirmation Tracking Management will establish a tracking mechanism (e.g., log or checklist) to monitor submission of all required 48-hour receipt confirmations. The tracking tool will document submission dates and ensure confirmations are submitted timely and retained in accordance with record retention requirements. 4. Assignment of Reporting Responsibility Management will formally assign primary responsibility for preparation and submission of Food Distribution Cluster reports to a designated individual. Roles and responsibilities will be clearly documented. 5. Supervisory Review and Oversight A supervisory reviewer will perform documented reviews of reconciliations, supporting documentation, and reports prior to submission. Supervisory review will confirm that: o Reconciliations are completed. o Differences are investigated and resolved; and o Reports comply with applicable federal and State requirements. 6. Monitoring and Training Management will periodically monitor compliance with these procedures and provide refresher training to staff involved in inventory, distribution, and reporting to ensure consistent application of controls. Expected Completion Date: Within 60–90 days Responsible Parties: Donavann Brooks, Inventory Control Manager (901-527-0422)
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