Corrective Action Plans

Finding 497414 (2023-001)

None 2023

CT

2023-001 SECURITY DEPOSITS Grantor: U.S. Department of Agriculture Award Name: Rural Rental Housing Loans Award Year: 2023 Award Numbers: Various CFDA Number: 10.415 Criteria: Tenant security deposit accounts must be fully funded and maintained in a separate bank account. Condition: During our audit...

2023-001 SECURITY DEPOSITS Grantor: U.S. Department of Agriculture Award Name: Rural Rental Housing Loans Award Year: 2023 Award Numbers: Various CFDA Number: 10.415 Criteria: Tenant security deposit accounts must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for tenant security deposits, it was not fully funded. Cause: Tenant security deposits subledger is not reconciled with tenant security deposits bank account to ensure account is fully funded. Effect: Tenant security deposits bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the tenant security deposits bank account is fully funded. Management’s Views and Corrective Action Plan: Management will subsequently correct this and transfer tenant funds received for their security deposit from the operating bank account to the tenant security deposits bank account to ensure it is fully funded.

View Audit 320161

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 497410 (2023-004)

Significant Deficiency 2023

City of Porterville

CA

Procurement, Suspension & Debarment

Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: The City should add a section to its standard contractor and subrecipient contracts for the other party to certify they are not suspended or otherwise debarred. In addition, internal controls should be u...

Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: The City should add a section to its standard contractor and subrecipient contracts for the other party to certify they are not suspended or otherwise debarred. In addition, internal controls should be updated to ensure that evident of the performance of suspension and debarment compliance is retained for future reference. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In response to the audit finding regarding the suspension and debarment status for all vendor before contract execution, we have communicated with all relevant staff on the importance of conducting debarment status checks prior to procurement and the requirement of SAM.gov check, with date noted as recommended, and evidence be saved in the contract file or the requirement that a certification of non-debarment status clause be included in contracts. To ensure compliance, we have instituted regular internal audits to verify SAM.gov checks are being conducted and properly documented for all contracts. Name of the contact person responsible for corrective action: Janie Rodriguez Planned completion date for corrective action plan: August 27, 2024

View Audit 320159

Finding 497408 (2023-003)

Significant Deficiency 2023

City of Porterville

CA

Reporting Internal Control / Segregation of Duties

Airport Improvement Program - Assistance Listing No. 20.106 Recommendation: The City should review its process for identifying and tracking Federal Aviation Administration reporting requirements to ensure that all required reports are submitted timely. Explanation of disagreement with audit finding:...

Airport Improvement Program - Assistance Listing No. 20.106 Recommendation: The City should review its process for identifying and tracking Federal Aviation Administration reporting requirements to ensure that all required reports are submitted timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent future occurrences, we are revising internal review procedures and establishing automated calendar reminders, to ensure that in the future, SF-425 reports will be submitted for all reporting periods. We are fully committed to maintaining compliance with all federal reporting requirements and will continue to improve our processes to prevent such issues in the future. Name of the contact person responsible for corrective action: Janie Rodriguez Planned completion date for corrective action plan: September 30, 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 497396 (2023-002)

None 2023

Alexandria Borough Water Authority

PA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.302 § 200.305 § 200.318 § 200.319 § 200.320

2023-002 U.S. Department of Environment Protection – Assistance Listing # 66.468 Capitalization Grants for Drinking Water State Revolving Fund (Drinking Water State Revolving Fund Cluster) Lack of Required Written Policies & Procedures – Compliance Condition & Criteria: The Authority does not c...

2023-002 U.S. Department of Environment Protection – Assistance Listing # 66.468 Capitalization Grants for Drinking Water State Revolving Fund (Drinking Water State Revolving Fund Cluster) Lack of Required Written Policies & Procedures – Compliance Condition & Criteria: The Authority does not currently have all the written policies and procedures in place as required by the Uniform Guidance as it relates to financial management and determining allowability of costs for the federal program (Title 2 U.S. Code of Federal Regulations (CFR) 200.302 & 200.305). In addition CFR sections 200.318, 200.319, and 200.320 require there to be written policies and procedures regarding procurement and conflicts of interest. Planned Corrective Action: The water systems improvements federally funded project is the Authority’s first time subject to the requirements of the Uniform Guidance as we have not had any significant grant funding since 2004. The Authority does have a set of informal policies and procedures that are followed as it relates to financial management, allowability of costs, procurement, and conflicts of interest, and have been very careful to carry out all federal program activities in accordance with established regulations; however, the Authority was simply not aware of the requirement that these polices and procedures be documented in writing. The Authority has been working over the past year to draft and develop these policies and procedures as they relate to federal programs, and to get them documented in writing. The Authority is currently working with their attorney to have the written polices established and plan to have this completed within the next fiscal year. Once the required policies are written, the Board of the Authority will review the policies, revise as appropriate, and adopt the policies for the Authority to comply with the federal funding requirements.

View Audit 320142

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 497392 (2023-004)

Significant Deficiency 2023

City of Laconia

NH

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

LACONIA SCHOOL DISTRICT CORRECTIVE ACTION PLAN Audit Finding Reference MW-2023-04 Planned corrective action: All prepared Journal Entries will be reviewed and approved by the preparer and one other business office individual (Payroll Accounting specialist or Accounts Payable coordinator) Name o...

LACONIA SCHOOL DISTRICT CORRECTIVE ACTION PLAN Audit Finding Reference MW-2023-04 Planned corrective action: All prepared Journal Entries will be reviewed and approved by the preparer and one other business office individual (Payroll Accounting specialist or Accounts Payable coordinator) Name of Contact person: Diane Clary, Business Administrator dclary@laconiaschools.org Anticipated completion date: September 30, 2024 Example of Planned Corrective Action: Journal entries will be printed by the preparer and reviewed and initialed by another business office employee.

View Audit 320135

Finding 497391 (2023-003)

Significant Deficiency 2023

City of Laconia

NH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness

LACONIA SCHOOL DISTRICT CORRECTIVE ACTION PLAN Audit Finding Reference MW-2023-03 Planned corrective action: All purchase orders will be approved by an Administrator and the Business Administrator. The current software allows for and audit path of approval, changes will be made to include the a...

LACONIA SCHOOL DISTRICT CORRECTIVE ACTION PLAN Audit Finding Reference MW-2023-03 Planned corrective action: All purchase orders will be approved by an Administrator and the Business Administrator. The current software allows for and audit path of approval, changes will be made to include the above practice in accordance with City and School District policy. Name of Contact person: Diane Clary, Business Administrator dclary@laconiaschools.org Anticipated completion date: September 30, 2024 Example of Planned Corrective Action: School ERP Pro software will be adjusted for an approval path including an Administrator and The Business Administrator.

View Audit 320135

Finding 497389 (2023-002)

Significant Deficiency 2023

Minnesota Indian Women's Sexual Assault Coalition

MN

Allowable Costs / Cost Principles § 200.303

It was determined during the 2022 audit that expenditures initiated by the Executive Director did not have the required approval. At the time of the 2022-002 finding, an update was made to the procedures in the Financial Policies and Procedures manual Part III, Sections 2 and 4 to address the use of...

It was determined during the 2022 audit that expenditures initiated by the Executive Director did not have the required approval. At the time of the 2022-002 finding, an update was made to the procedures in the Financial Policies and Procedures manual Part III, Sections 2 and 4 to address the use of MIWSAC credit/debit cards for expenditures. This update was included with the corresponding corrective action plan in August 2023. The Executive Director’s credit/debit card purchases and expense reimbursement requests are now approved by the Keeper of Finances or the Keeper of Traditional Ways. This corrective action was fully implemented November 1, 2023. Corrective Action responsible party: Lisa Case, Fractional Controller – All In One Accounting lisa.case@allinoneaccounting.com 651-374-4460 Corrective Action contact: Nicole Matthews, Executive Director nmatthews@miwsac.org 651-646-4800

View Audit 320126

Finding 497384 (2023-003)

Significant Deficiency 2023

Minnesota Indian Women's Sexual Assault Coalition

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

During 2023, vacation was paid out for a terminated employee. This payment did not agree with the organization’s vacation policy and documented approval of the decision was not available. Involuntary terminations at MIWSAC are rare. In the case of the terminated employee, vacation was paid out as th...

During 2023, vacation was paid out for a terminated employee. This payment did not agree with the organization’s vacation policy and documented approval of the decision was not available. Involuntary terminations at MIWSAC are rare. In the case of the terminated employee, vacation was paid out as though the termination was a voluntary resignation. This error was an oversight during payroll processing. As a result of this finding, the current policies & procedures surrounding payout of earned, unused vacation will be reviewed at an upcoming Circle Keepers meeting. Any approved changes to the policy will be documented in the Employee Handbook and distributed to all employees. This corrective action will be completed no later than September 30, 2024 Corrective Action contact/responsible party: Nicole Matthews, Executive Director nmatthews@miwsac.org 651-646-4800

View Audit 320126

Finding 497380 (2023-001)

Significant Deficiency 2023

Presbyterian Healthcare Services

NM

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.318 § 200.319 § 200.320

Finding 2023-001 – Internal control deficiency and noncompliance over Procurement 1) Communication & Awareness: • Debrief by Director, Research and Sponsored Awards with the Community Health Department Senior Leaders and Program Managers regarding the audit finding; including procurement requirem...

Finding 2023-001 – Internal control deficiency and noncompliance over Procurement 1) Communication & Awareness: • Debrief by Director, Research and Sponsored Awards with the Community Health Department Senior Leaders and Program Managers regarding the audit finding; including procurement requirements, the nature of the deficiency and failure points. This occurred on 8/27/2024. • Meeting between Director, Research and Sponsored Awards, PHS Communications and Brand Management leadership and VP of Community Health to communicate procurement requirements and clarify responsibilities for communication of applicability of Federal procurement requirements to specific projects for which advertising services are requested. Initial Meeting occurred 8/28/2024. 2) Training & Education: • Targeted Training with the Community Health department (primary recipient of on-going Federal funding) on Federal procurement requirements. This training will be provided by the Research and Sponsored Awards staff and will be extended to any additional departments new to Federal funding. • Enhancement of existing required annual enterprise-wide leadership training that includes a section on grant funding with increased emphasis on procurement. Research and Sponsored Awards department is responsible for content. • Development of materials for new hires or others new to grant funding who are responsible for federally funded projects (collaboration between Research and Sponsored Awards department and Community Health department) 3) Policies & Procedures: • Written Procedures & Toolkits: Development of written procedures for contracting, exclusion checks and general procurement of goods or services to include checklists / toolkits to facilitate actions required for compliance with Federal procurement rules. • Update to existing policy “Federally funded Grants or Contracts – Procurement / Purchase of Supplies, Services and Other Property” to clarify the responsibilities for communication of applicability of Federal procurement requirements when a department receiving Federal funding procures goods or services through other PHS departments. 4) Collaboration with PHS Marketing department to ensure pathways exist for competitive bids, when necessary, including documentation of processes related to procurements under Federal funding. The first meeting was held 9/12/2024. 5) The Director, Research and Sponsored Awards and Community Health Department will review the items identified as questioned costs to identify if any improper payments were made to PHS. Contact Person: Lori Galves, Director, Research and Sponsored Awards Anticipated Completion Date: December 31, 2024

View Audit 320124 Questioned Costs: $1

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 497374 (2023-005)

Material Weakness 2023

Southwest Health and Human Services

MN

Eligibility Material Weakness Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-005 Finding Title: Eligibility – METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Corey Remiger – Eligibility Supervisor Ashley VanOverbeke- Eligibility Supervisor Corrective Actio...

Finding Number: 2023-005 Finding Title: Eligibility – METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Corey Remiger – Eligibility Supervisor Ashley VanOverbeke- Eligibility Supervisor Corrective Action Planned: The planned corrective action is to continue reminding and reviewing with staff on a regular basis and at unit meetings the need to utilize checklists with all applications and renewals so all required documentation is on file, verify income and asset requirements, and complete case transfers correctly. Supervisors and/or Lead Workers will also complete case reviews for accuracy. Anticipated Completion Date: October 31, 2024

View Audit 320115

Finding 497373 (2023-004)

Material Weakness 2023

Southwest Health and Human Services

MN

Eligibility Material Weakness Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-004 Finding Title: Eligibility – MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Corey Remiger – Eligibility Supervisor Ashley VanOverbeke- Eligibility Supervisor Corrective Actio...

Finding Number: 2023-004 Finding Title: Eligibility – MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Corey Remiger – Eligibility Supervisor Ashley VanOverbeke- Eligibility Supervisor Corrective Action Planned: The planned corrective action is to continue reminding and reviewing with staff on a regular basis and at unit meetings the need to utilize checklists with all applications and renewals so all required documentation is on file, verify income and asset requirements, and complete case transfers correctly. Supervisors and/or Lead Workers will also complete case reviews for accuracy. Anticipated Completion Date: October 31, 2024

View Audit 320115

Finding 497371 (2023-003)

Material Weakness 2023

Southwest Health and Human Services

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-003 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles, and Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Office...

Finding Number: 2023-003 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles, and Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey – Fiscal Officer Corrective Action Planned: The planned corrective action is to review report instructions regularly, accurately identify appropriate eligible revenue and expenditures for each report and review for accuracy by implementing secondary review of the data that is being reported. The FTE payroll splits have been implemented in the current year. Anticipated Completion Date: October 31, 2024

View Audit 320115

Finding 497369 (2023-002)

Material Weakness 2023

Southwest Health and Human Services

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.563 Child Support Enforcement Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey...

Finding Number: 2023-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.563 Child Support Enforcement Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey – Fiscal Officer Corrective Action Planned: The planned corrective action is to review report instructions regularly, accurately identify appropriate eligible revenue and expenditures for each report and review for accuracy by implementing secondary review of the data that is being reported. The FTE payroll splits have been implemented in the current year. Anticipated Completion Date: October 31, 2024

View Audit 320115

Finding 497367 (2023-002)

None 2023

Hamakua Health Center, Inc.

HI

Procurement, Suspension & Debarment § 200.320

Finding 2023-002 – Inadequate Design of Monitoring Controls over Procurement Policies Although Hamakua Health staff were not able to provide all the procurement records required by the auditors in the short period of time that was given, these procurement documents should have been scanned by those ...

Finding 2023-002 – Inadequate Design of Monitoring Controls over Procurement Policies Although Hamakua Health staff were not able to provide all the procurement records required by the auditors in the short period of time that was given, these procurement documents should have been scanned by those who initiated and completed the procurement processes and kept them in a ShareFile for easier access, especially for those contracts that are still active. This is now the new standard practice for all new procurement processes. Procurement policies that are complete, correct, and compliant exist have been and are in use at the Health Center. A process has been implemented where a daily purchases receipts log is kept, Purchase Orders and Packing Slips are scanned and attached to invoices to process for payment. Corrective actions have already been implemented at this time. Responsible person to be contacted regarding management responses: John R. White, MHA, BA, CHW Chief Executive Officer jwhite@hamakua-health.org 808.930.2745

View Audit 320114

Finding 497365 (2023-001)

Significant Deficiency 2023

New Vision House of Hope, Inc.

MD

Reporting

To ensure Financial Statements are prepared in a timely manner for the annual single audit and submission of the Data Collection Forms, NVHOH will meet with L TH Accounting Services on a monthly basis.

View Audit 320110

Finding 497364 (2023-002)

Material Weakness 2023

Hip Housing Development Corporation

CA

Internal Control / Segregation of Duties Material Weakness Reporting

We acknowledge the audit finding concerning the number of account balances that required adjustments and the resulting audit adjusting journal entries. 1. System Conversion: Recently, we underwent a comprehensive system conversion and creation of uniform chart of accounts for all the properties and ...

We acknowledge the audit finding concerning the number of account balances that required adjustments and the resulting audit adjusting journal entries. 1. System Conversion: Recently, we underwent a comprehensive system conversion and creation of uniform chart of accounts for all the properties and entities in our portfolio, which, while beneficial in the long term, contributed to the initial discrepancies in our account balances. 2. Improvement in Adjusting Entries: We are pleased to note that there has been a significant reduction in the number of adjusting entries required this year compared to previous years. This indicates that the measures we have put in place are moving us in the right direction. 3. Additional Support: To further support our efforts, we have hired a new accounting manager. This addition to our team will provide the necessary expertise and oversight to ensure accurate transaction recording and reconciliation. 4. Process Improvements: We have implemented several process improvements to streamline data entry, making the recording of transactions more efficient and reducing the likelihood of errors. 5. Enhanced Review Process: To further ensure the accuracy of our financial records, we will implement a review process for all journal entries before they are posted to the general ledger. This additional layer of oversight will help identify and correct any discrepancies early in the process. We are confident that these actions will enhance the accuracy of our financial transactions and reduce the need for adjusting journal entries in future audits. Management is committed to continuous improvement and will closely monitor these changes to ensure their effectiveness.

View Audit 320105

Finding 497363 (2023-001)

Material Weakness 2023

Hip Housing Development Corporation

CA

Material Weakness Reporting Internal Control / Segregation of Duties

We acknowledge the audit finding regarding the timeliness of our financial reconciliation and not having reconciled financials available within a reasonable period after the fiscal year end. HIP Housing had a system conversion from QuickBooks to Yardi in July 2021. Our go live date was July 1, 2021 ...

We acknowledge the audit finding regarding the timeliness of our financial reconciliation and not having reconciled financials available within a reasonable period after the fiscal year end. HIP Housing had a system conversion from QuickBooks to Yardi in July 2021. Our go live date was July 1, 2021 which makes fiscal year 22-23 our second year of audit in our new system for HHAV, HIP Housing, and HHDC. This comprehensive system conversion delayed the closing of FY 21-22 which also impacted the timing of the FY 21-22 audit. The delay in FY 21-22 audit made it difficult for us to deliver the reconciled financials and trial balances for the FY 22-23 audit by the beginning of December. Once we missed the December deadline, we had to wait until the end of April to start the audit. We recognize the importance of timely financial reconciliation and have taken several measures to address this issue and prevent recurrence in future fiscal years. 1. Review and Enhancement of Processes: We have conducted a thorough review of our existing processes and procedures for identifying and reconciling financials. As a result, we have implemented more efficient and streamlined processes to ensure timely and accurate financial reporting. 2. System Conversion: The recent system conversion, while initially causing delays, has now been fully integrated into our operations. This new system is designed to enhance our financial management capabilities and support faster and more accurate financial reconciliations. 3. Addition of Key Personnel: To further strengthen our financial team, we have hired an experienced accounting manager. This new team member brings a wealth of expertise and will play a crucial role in overseeing the financial reconciliation process, ensuring that all entries are reviewed and finalized promptly. We are confident that these improvements will significantly enhance our ability to provide complete and reconciled financials within a reasonable period after the fiscal year end. Management remains committed to continuous improvement and will monitor the effectiveness of these changes to ensure ongoing compliance and efficiency.

View Audit 320105

Corrective Action Plans

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