State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-011 - CACFP Subrecipient Monitoring Name of the contact person responsible for corrective action: Sarah Walker, Administrator, Bureau of Co...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-011 - CACFP Subrecipient Monitoring Name of the contact person responsible for corrective action: Sarah Walker, Administrator, Bureau of Community Food and Nutrition Assistance (BCFNA), Division of Community and Public Health Anticipated completion date for corrective action: Not Applicable The Missouri Department of Health and Senior Services (DHSS) disagrees with this finding because the BCFNA subrecipient monitoring, claim recoupment and risk assessment procedures comply with the U.S. Department of Agriculture (USDA), the federal funding agency. In addition, the similar fiscal year 2023 audit finding was closed by the USDA after reviewing DHSS’s corrective action plan and supporting documentation. The SAO stated, “While our review found the sample monitoring reviews were performed in accordance with the policies and procedures outlined in the Internal Nutritionist Manual, we identified areas where these policies and procedures could be strengthened and improved to ensure facilities/sponsors comply with program requirements and submit proper claims.” The SAO is holding DHSS to higher performance audit standards instead of Single Audit compliance audit standards as well as to higher standards than required by federal guidance and regulations. The SAO’s stated, “In May 2024, when the BCFNA changed the risk assessment and scoring system, the BCFNA ceased assigning a grade of A, B, B-, or C to each review and widened the score ranges and associated review requirements. DHSS officials indicated the scores assessed by the new system are frequently higher than those assessed under the previous manual system. The impact of these changes on the frequency and effectiveness of the monitoring reviews is unclear.” While working with the software provider during the development, testing, and implementation stages over the course of several years, the new point range was thoroughly reviewed prior to implementation. This ensured reviews are classified appropriately for risk categories. The new system provides a monitoring process more stringent than USDA requirements. All monitoring is reviewed by supervisory staff to ensure a comprehensive assessment. During testing, it was found that the new system frequently returned a higher point level, as every finding now results in a point. The increased score range was required to more precisely reflect monitoring reviews and reflects an even more stringent monitoring process than is required by USDA. The SAO reported “….BCFNA only identifies and seeks recoupment for the overclaims made during the test month.” As noted in previous CAPs, BCFNA pursues recoupment of overclaims of only the test month per USDA requirements, although when warranted, additional reviews are conducted beyond the test month. In addition, BCFNA officials pursue recoupment of overclaims for facilities/sponsors with terminated contracts on a case-by-case basis, taking into consideration various factors. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. The previous and current risk assessment processes are in compliance with federal requirements. BCFNA has a structured risk assessment process that informs its monitoring extent and frequency, which leads to subrecipients being monitored more frequently than every three years as required by the USDA. The USDA is aware of the risk assessment process used by BCFNA and did not require any changes to the process after the previous three similar findings by the SAO. As stated in previous CAPs on similar findings, the DHSS is in compliance with USDA guidelines and requirements for CACFP and implementing the SAO’s recommendations would cause undue burden on the participants and providers of this program which USDA warns against. In addition, the SAO applied the same testing methodology and error projection approach to determine materiality for this finding as it did for finding 2025-010. Accordingly, DHSS maintains the same position and arguments previously presented.