Corrective Action Plans

Finding 1172051 (2024-001)

Material Weakness 2024

AR

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Recommendation:We recommend that management develop, implement, and maintain written policies and procedures documenting its system of internal control over federal programs to ensure compliance with Uniform Guidance and applicable federal requirements. Views of Responsible Officials and Planned Cor...

Recommendation:We recommend that management develop, implement, and maintain written policies and procedures documenting its system of internal control over federal programs to ensure compliance with Uniform Guidance and applicable federal requirements. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and plans to develop and implement written internal control policies and procedures over federal programs. Management anticipates completion by June 30, 2026.

View Audit 385167

Finding 1172037 (2024-004)

Material Weakness 2024

Biddeford-Saco-Old Orchard Beach Transit Committee

ME

Procurement, Suspension & Debarment § 200.318

2024-004 Procurement, Suspension and Debarment The Committee acknowledges that certain procurement procedures were not followed, leading to a finding of noncompliance. To remedy this, on July 1, 2025 we put new workflow controls in place within our new integrated accounting software. These workflows...

2024-004 Procurement, Suspension and Debarment The Committee acknowledges that certain procurement procedures were not followed, leading to a finding of noncompliance. To remedy this, on July 1, 2025 we put new workflow controls in place within our new integrated accounting software. These workflows support compliance with our procurement policies and ensure all required supporting documentation, including forms for micro and small purchases, are secured and archived for capital purchases and grant expenditures. This will ensure that all procurement policies, which are in compliance with all FTA guidelines, are consistently followed.

View Audit 385115

Finding 1172036 (2024-003)

Material Weakness 2024

Biddeford-Saco-Old Orchard Beach Transit Committee

ME

Allowable Costs / Cost Principles § 200.302

2024-003 Allowable Costs/Cost Principles: Written Financial Policies The Biddeford-Saco-Old Orchard Beach Transit Committee acknowledges the need to formally adopt certain written financial management policies as outlined in federal regulations. The new finance manager is currently working to draft ...

2024-003 Allowable Costs/Cost Principles: Written Financial Policies The Biddeford-Saco-Old Orchard Beach Transit Committee acknowledges the need to formally adopt certain written financial management policies as outlined in federal regulations. The new finance manager is currently working to draft and formalize these policies and procedures with a targeted completion date of March 31, 2026. We will present them to the Board of Directors for review and official adoption.

View Audit 385115

Finding 1172035 (2024-002)

Material Weakness 2024

Biddeford-Saco-Old Orchard Beach Transit Committee

ME

Allowable Costs / Cost Principles § 200.303

2024-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all empl...

2024-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all employees are now required to create a purchase order (PO) and obtain approvals before payments can be made. This process controlled by the finance manager creates a complete audit trail for every transaction, ensuring that all disbursements are properly documented.

View Audit 385115

Finding 1171960 (2024-005)

Material Weakness 2024

Galveston County Health District

TX

Eligibility Material Weakness Internal Control / Segregation of Duties

Finding: 2024-005 Material Weakness in Internal Control Over Eligibility – WIC Special Supplemental Nutrition Program for Women, Infants, and Children (10.557) Corrective Action: We will develop a checklist for eligibility documentation and conduct quarterly file reviews and implement corrective act...

Finding: 2024-005 Material Weakness in Internal Control Over Eligibility – WIC Special Supplemental Nutrition Program for Women, Infants, and Children (10.557) Corrective Action: We will develop a checklist for eligibility documentation and conduct quarterly file reviews and implement corrective actions as a result of those reviews. We will also provide training to program staff on the eligibility documentation requirements. Proposed Completion Date: February 28, 2026 Name of Contact Person:Tomiko Fisher, Chief Operating Officer

View Audit 385024

Finding 1171959 (2024-003)

Material Weakness 2024

Galveston County Health District

TX

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding: 2024-003 Material Weakness in Internal Control Over Allowable Costs/Cost Principles and Reporting – WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (10.557, 93.268) Corrective Action: We will work to ensure that the proper...

Finding: 2024-003 Material Weakness in Internal Control Over Allowable Costs/Cost Principles and Reporting – WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (10.557, 93.268) Corrective Action: We will work to ensure that the proper indirect cost rate is applied to the various grants. Proposed Completion Date: February 28, 2026 Name of Contact Person: Tomiko Fisher, Chief Operating Officer

View Audit 385024

Finding 1171958 (2024-002)

Material Weakness 2024

Galveston County Health District

TX

Reporting Material Weakness Period of Performance

Finding: 2024-002 Material Weakness in Internal Control Over Period of Performance – Health Center Program, WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (93.224, 10.557, 93.268) Corrective Action: The District is in the process ...

Finding: 2024-002 Material Weakness in Internal Control Over Period of Performance – Health Center Program, WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (93.224, 10.557, 93.268) Corrective Action: The District is in the process of developing a comprehensive year-end closing checklist and has already streamlined many of the procedures that caused reconciliation issues. In addition, we will perform spot checks on transactions to ensure that payroll and nonpayroll expenditures are recorded in the proper period. We will also provide additional training to ensure that personnel only record expenditures when confirmation has been received of receipt of goods or services. Proposed Completion Date: February 28, 2026 Name of Contact Person: Tomiko Fisher, Chief Operating Officer

View Audit 385024

Finding 1171947 (2024-004)

Material Weakness 2024

Galveston County Health District

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Special Tests & Provisions

Finding: 2024-004 Material Weakness in Internal Control Over Special Tests – Health Center Program (93.224) Corrective Action: We will develop a checklist for patient discount documentation and implement a control requiring supervisor approval for overrides. We will also perform monthly file audits ...

Finding: 2024-004 Material Weakness in Internal Control Over Special Tests – Health Center Program (93.224) Corrective Action: We will develop a checklist for patient discount documentation and implement a control requiring supervisor approval for overrides. We will also perform monthly file audits and report exceptions to the appropriate personnel. Proposed Completion Date: February 28, 2026 Name of Contact Person: Lane Baker, CHW Chief Operating Officer

View Audit 385024

Finding 1171942 (2024-002)

Material Weakness 2024

City of Williamsport

PA

Reporting

Finding 2024-002 Reporting Corrective Action: The City discovered and corrected the error during 2024, at which time additional reviews were implemented over report submission. The error has been corrected with 2025 reporting.

View Audit 385019

Finding 1171932 (2024-005)

Material Weakness 2024

Sexual Assault Victim Advocate Center

CO

Allowable Costs / Cost Principles

Planned Corrective Action: SAVA Center experienced a change in leadership in September 2024. The new Executive Director discovered that several invoices had been submitted to VOCA for reimbursement for costs not approved in the grant budget. The new Executive Director worked with VOCA to submit corr...

Planned Corrective Action: SAVA Center experienced a change in leadership in September 2024. The new Executive Director discovered that several invoices had been submitted to VOCA for reimbursement for costs not approved in the grant budget. The new Executive Director worked with VOCA to submit corrected invoices and withhold the unallowable costs from a subsequent reimbursement request, and created a new grant management tracking system. This system includes an Excel workbook that tracks grant allocations, and grant spending for each individual budget, to ensure SAVA is in compliance. Name of Contact Person: Alison Jones-Lockwood, Executive Director Anticipated completion date: October 31, 2024

View Audit 384965

Finding 1171931 (2024-004)

Material Weakness 2024

Sexual Assault Victim Advocate Center

CO

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

Planned Corrective Action: SAVA Center’s new Executive Director added information about the requirements for a single audit to the newly updated ﬁnancial policies, reﬂecting that it is the responsibility of the Executive Director to monitor when a single audit is warranted. The Executive Director wi...

Planned Corrective Action: SAVA Center’s new Executive Director added information about the requirements for a single audit to the newly updated ﬁnancial policies, reﬂecting that it is the responsibility of the Executive Director to monitor when a single audit is warranted. The Executive Director will maintain a spreadsheet summarizing the Schedule of Federal Expenditures (SEFA) and provide this to the auditor engaged to perform the Single Audit. Name of Contact Person: Alison Jones-Lockwood, Executive Director Anticipated completion date: January 12, 2026

View Audit 384965

Finding 1171930 (2024-001)

Material Weakness 2024

Sexual Assault Victim Advocate Center

CO

Internal Control / Segregation of Duties Subrecipient Monitoring

Planned Corrective Action: Prior to the completion of the 2024 Audit, SAVA Center’s Executive Director began revising and updating the organizational ﬁnancial policies. These policies have been reviewed by the SAVA Center Finance Committee and voted for approval on January 16th, 2026. The updated ﬁn...

Planned Corrective Action: Prior to the completion of the 2024 Audit, SAVA Center’s Executive Director began revising and updating the organizational ﬁnancial policies. These policies have been reviewed by the SAVA Center Finance Committee and voted for approval on January 16th, 2026. The updated ﬁnancial policies now contain detailed information on the segregation of duties, which now includes the following people: The Director of Operations (in-house bookkeeper and preparer of grant invoices), the contract Accountant (allocates payroll, prepares monthly ﬁnancial statements, and assists with preparing the organization budget), the Executive Director (signer of checks, holder of bank card, reviews all grant invoices prior to submission, monitors revenue/expenses, and monthly ﬁnancials), and the Board Treasurer (reviews and presents monthly ﬁnancials, signing authority, chairs the ﬁnance committee, and provides opinion when needed on accounting best practices). Name of Contact Person: Alison Jones-Lockwood, Executive Director Anticipated completion date: January 16, 2026

View Audit 384965

Finding 1171926 (2024-012)

Material Weakness 2024

Community Benefit Solutions

PA

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

2024-012 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-012 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth) review of CBS Food Program's financial accounting system, it was noted that the Food Program utilizes QuickBooks software for their accounting system. Based on inquiry with CBS Food Program management, we determined internal controls connected with their QuickBooks accounting software were insufficient in the following areas: • User Access Management: Formal written policies or procedures have not been developed and implemented related to access authorization, access monitoring, and removal of system access. Additionally, certain functions are not properly segregated as users have access to perform both input and authorization of transactions. • Input Management: Formal written policies or procedures to ensure information input into QuickBooks is appropriate and accurate have not been developed and implemented. • Change Control Management: A formal written change management policy for QuickBooks Accounting System has not been developed and implemented including requirements that system security updates are implemented timely. • Backup and Recovery: A formal written policy for regular backup and recovery testing has not been developed and implemented. Recommendation: We recommend that CBS Food Program develop and implement comprehensive written internal control policies and procedures connected with their QuickBooks Accounting System. This should include: • Development and utilization of an Accounting Manual which includes an outline of CBS Food Program's accounting rules, procedures, and guidelines. • Access control policies and procedures to ensure that user access to QuickBooks is appropriate, regularly reviewed and promptly revoked upon termination or when otherwise merited. Recommendation (Continued) • A formal written change management policy for QuickBooks should be developed and implemented including requirements that systems security updates are implemented timely. • A disaster recovery plan and procedures to perform periodic testing to ensure that plans are functional and mitigate the risk of extended downtime. This process should also include regular review of backup records to ensure they are appropriately created and maintained. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions does not dispute this finding. Community Benefit Solutions will migrate from Quickbooks Desktop to Quickbooks Online, which will provide a perfect transitional opportunity to re-evaluate processes, and to develop and implement necessary controls over its systems. Community Benefit Solutions will work with independent auditors, internal information technology team, and, if necessary, legal counsel to plan, draft, and implement the relevant internal controls. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171925 (2024-011)

Material Weakness 2024

Community Benefit Solutions

PA

School Nutrition Programs Internal Control / Segregation of Duties Material Weakness

2024-011 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-011 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth) review of CBS Food Programs banking policies, it was noted that the CBS Food Program did not establish appropriate controls to ensure bank account access changes and bank account closures could be promptly completed when organizational or personnel changes merited such actions. CBS Food Program management noted two instances during the engagement period in which lack of cooperation from parties with CBS Food Program bank account authority or access prevented the Food Program from closing bank accounts in an expeditious manner. This resulted in the CBS Food Program simultaneously having bank accounts open at three different banks for a portion of the audit period. As of May 2025, CBS Food Program only actively banks with one institution. Of the accounts with the other institutions, one account is closed, and the other remains open, but inactive because CBS Food Program has not initiated any account-related activity for an extended period of time. According to CBS Food Program management, they are working to close the inactive account, but closure requires assistance from Congregation Beth Solomon which has not been cooperative. The Commonwealth noted that CBS Food Program has inefficient control procedures in place over the issuance of high-value checks. Following the separation of CBS Food Program's prior CEO, the Food Program opened a new bank account in order to remove the prior CEO's access to food program funds. The former CEO was not cooperative in removing his access to the bank account the Food Program used at the time of his separation, so CBS Food Program determined moving the Food Program's funds to a new bank was in the best interest of the organization. To move the Food Program's funds from the old bank to the new bank, CBS Food Program's Director of Finance wrote two checks for $1.5 million dollars each. While CBS Food Program's Director of Finance obtained approval from the board prior to preparing and depositing the checks in the new bank account, a secondary signature was not obtained as CBS Food Program policy did not require a second signature for any check regardless of amount. Recommendation: CBS Food Program should assign bank authorization and access roles to appropriate CBS representatives to ensure access is appropriately limited, but that changes to account authorization can be completed timely when organizational or personnel changes merit such modifications. CBS Food Program should establish, document, and adhere to, a policy requiring documented prior approval and dual signatures on checks exceeding a predetermined threshold set by management and/or the board of directors. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Planned completion date for corrective action plan: June 30, 2025 Action taken in response to finding: Community Benefit Solutions does not dispute this finding and provides the following for the purpose of additional clarification. Between February 14, 2024, and June 10, 2024, the departure of the Farmer CEO and several key Board members resulted in the absence of authorized signers. In order to expeditiously remove individuals from accessing bank funds during this transition, the Community Benefit Solutions Board of Directors granted the Accounting Associate authority to sign all relevant checks and take steps necessary to remove those individuals. Going forward, Community Benefit Solutions will, with the assistance of either Board-approved counsel or outside independent audit firm, develop and implement thresholds for dual signature requirements. Moreover, Community Benefit Solutions will work with JP Morgan Chase Bank to ensure that authorization and authority can be expeditiously amended in the event such a need arises.

View Audit 384963

Finding 1171924 (2024-010)

Material Weakness 2024

Community Benefit Solutions

PA

Procurement, Suspension & Debarment School Nutrition Programs Internal Control / Segregation of Duties

2024-010 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-010 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on interviews by the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (“Commonwealth”) with CBS Food program management, inspection of records, and on-site observations, we identified internal control deficiencies in the following areas: • For a portion of the audit period, there was a lack of segregation of duties between the cash receipt, bookkeeping, and bank reconciliation processes. The Director of Finance was responsible for all these tasks. The Director of Finance was also responsible for both processing and approving payroll and had authorization to make purchases, make vendor payments, record accounting transactions and complete bank reconciliations. • CBS Food Program performs bank reconciliations; however, they are not signed or dated by the individual performing the reconciliation and a second individual does not review or sign off on the reconciliations. Of nine reviewed account reconciliations, three were completed more than 30 days after the statement period end date. • According to CBS Food Program's former Purchasing Distribution Manager, as of June 2024, they were the only CBS Food Program's employees with detailed knowledge of developing monthly menus and creating purchase orders based on current inventory levels to meet menu requirements. Additionally, the former Purchasing Distribution Manager stated that as of June 2024 formal training on internal purchasing policies and procedures is not provided or required. Condition (Continued) • For a portion of the engagement period, CBS Food Program lacked written policies or procedures for several key business functions including: o No written Accounting Manual or Standard Operating Manual for accounting functions. o No written policy or procedure for the use of credit cards or the handling of lost or stolen credit cards. o No written policy or procedure to analyze account balances to ensure transactions have been properly recorded. o No written records retention policy. o No written procedures for handling payroll for separating employees. o No written or implemented review process for changes to the payroll system including changes to employee payrates. o For a portion of the engagement period, the Food Program did not have procedures to o Prior to July 1, 2024, CBS Food Program did not have documented procurement procedures. On July 1, 2024, CBS Food Program implemented a procurement plan. Recommendation: If not already addressed, CBS Food Program should develop and implement improved internal controls including: • Develop written policies, procedures and/or manuals for accounting functions. • Develop a formal internal control policy and framework that focuses on key business and operations areas including segregation of duties, transaction review and approval processes, and monitoring procedures over critical operational functions. • Improve cross training of employees including training on purchasing and accounting tasks. • CBS Food Program should develop and implement a record retention policy that complies with food program requirements for maintaining documentation of operations. The policy should ensure key records are maintained in a shared location accessible to all appropriate personnel. This ensures the CBS Food Program does not lose access to key records in the event an employee leaves the food program. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions will work with its outside independent audit firm, Board-approved counsel, and other necessary stakeholders to develop and implement all the necessary controls as required by the Comptroller. Community Benefit Solutions' implementation of any of the noted changes will be the ability to recruit Finance Committee and Nutrition Committee members of the Board. Moreover, Community Benefit Solutions made strides in implementing some of the requested policies during the Audit. Community Benefit Solutions will endeavor to meet each of the requests despite any lack of human capital that would allow for ease of segregation of authority. Community Benefit Solutions is optimistic that incoming Board Members and external accounting, audit, HR, and legal will provide critical support. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171923 (2024-009)

Material Weakness 2024

Community Benefit Solutions

PA

School Nutrition Programs

2024-009 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-009 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth), testing and calculations of the CBS Food Program's Net Cash Resources Available and their 3 months averages expenditures, the Commonwealth determined the Food Program's net cash resources exceeded their 3 months average expenditures as of June 30, 2024. The Commonwealth calculated both 3-month average operating expenditures and Net Cash Resources Available based on financial statement information provided by CBS Food Program. The Commonwealth's calculations of Net Cash Resources found that the Food Program exceeded their 3 months average expenditures by $2,354,119 as of June 30, 2024. The Pennsylvania Department of Education (PDE) has been communicating with CBS Food Program to develop plans for spending down their excess non-profit food program balance. Recommendation: CBS Food Program should work with PDE to develop a plan to appropriately utilize its resources. In the future, the Food Program should monitor cash resources to ensure they do not exceed maximum thresholds required by federal regulations. Excess food program resources can be used to improve or expand the nonprofit food service for program participants. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions agrees in principle with this finding; however, disputes the amount of Net Cash Resources Available in Excess of Federal Regulation. Based on the 2025 Year End Balance, CBS Food Program has $1,087,495.35 in cash and $2,106,728.79 in Certificates of Deposits which totals $3,194,224.11 in Net Cash Resources. CBS Food Program's expenditures during the 24-25 Program Year totaled $8,542,614, which results in allowable Net Cash Resources of$2,135,653.50 (three months of total expenditures). More accurately, the expected expenditures for the 25-26 Program Year are $7,167,206, results in allowable Net Cash Resources of $1,791,801.50. Accordingly, Community Benefit Solutions contends that the Net Cash Resources Available in Excess of Federal Regulations is $1,793,571. Prior to the issuance of the Draft Report, Community Benefit Solutions provided PDE with a preliminary Spend Down Proposal based on an expected $2,800,000 in excess funds. The Spend Down Proposal included, among other things, $837,000 set aside for the purpose of equipping Community Benefit Solutions' new headquarters with a commercial kitchen, refrigerator, and freezer (the "Warehouse Buildout"). PDE approved the portion of the Spend Down Plan pertaining to the Warehouse Buildout. The Board of Directors along with Community Benefit Solutions leadership and PDE will continue to coordinate and determine appropriate and allowable actions to spend down Net Cash Resources in accordance with the federal requirements. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171922 (2024-007)

Material Weakness 2024

Community Benefit Solutions

PA

Subrecipient Monitoring School Nutrition Programs Internal Control / Segregation of Duties § 200.332

2024-007 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-007 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of subrecipient monitoring activities for PDE programs CACFP, NLSP, and SFSP, we selected 31 contracted centers at random. Management provided documentation for each site, including contracts, meal pattern usage records, licensure and training documentation, and both announced and unannounced meal observation reviews. However, we found that CBS Food Program did not always maintain sufficient evidence to prove required monitoring was performed under the CACFP program. For one center, management could not produce proof that meal observation reviews or the mandated two unannounced visits occurred. At another center, neither a contract nor any meal observation review records, including the two required unannounced visits, could be provided. For the NLSP and SFSP, management was unable to provide contracts for any of the seven sampled centers. Additionally, there was no evidence of training for one center, and a second center had a noncompliant monitoring visit; although corrective action was prepared, follow-up occurred only after 66 days instead of within the required 45-day window. Recommendation: We recommend that management strengthen internal controls to ensure all required PDE CACFP, NLSP and SFSP subrecipient monitoring activities, including scheduled meal observations and the mandated unannounced visits—are consistently performed, documented, and retained. Management should implement a centralized tracking system to monitor review deadlines, required follow up actions, and receipt of supporting documentation from each contracted center. In addition, staff responsible for monitoring should receive periodic refresher training on PDE CACFP, NLSP and SFSP specific expectations. Finally, management should conduct periodic internal reviews to verify that monitoring documentation is complete, compliant, and appropriately maintained. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions shall utilize internally developed Quickbase application to schedule and track monitoring visits including ensuring necessary corrective action follow-ups are conducted within 45 days documented corrective action needed. Moreover, Community Benefit Solutions will require all monitoring staff to successfully complete monitoring specific training in addition to the annual and civil rights training to ensure up to date knowledge of all requirements. Trainings will be assigned, monitored and signed off on by Director of Operations. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171921 (2024-006)

Material Weakness 2024

Community Benefit Solutions

PA

Procurement, Suspension & Debarment School Nutrition Programs § 200.213

2024-006 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-006 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of our procurement testing in accordance with Uniform Guidance requirements, we requested that management provide the most recent suspension and debarment assessments for the vendors selected for review. Our analysis indicated that management did not perform these assessments by reviewing the federal government's suspended or debarred vendor list on SAM.gov. Rather, they relied on vendor certifications obtained through the Commonwealth of Pennsylvania, Department of Education, to determine vendor eligibility with respect to suspension or debarment from federally funded programs. Additionally, we observed that the current procurement policy for the CBS Food Program does not outline a formal procedure for evaluating vendors' suspension and debarment status as required by Uniform Guidance. Recommendation: We recommend that management establish and implement a formal process for evaluating vendors regarding suspension and debarment. This process should include regular reviews of the federal government's suspended or debarred list on SAM.gov to ensure that vendors are not suspended or debarred from participating in federal programs. Additionally, management should ensure that all procurement policies and procedures are updated to reflect this requirement. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions shall update its current procurement policy to include a suspension and debarment review of all vendors seeking to do business with the organization. Prior to February 13, 2026, Community Benefit Solutions shall conduct a comprehensive review of all current vendors to ensure compliance with these recommendations. Community Benefit Solutions will update procurement policy to include quarterly suspension and debarment review to be conducted by Quality Assurance Associate and signed off on by Warehouse and Purchasing Director. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171920 (2024-005)

Material Weakness 2024

Community Benefit Solutions

PA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

2024-005 Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of participant eligibility, we selected a sample of 40 participants receiving me...

2024-005 Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of participant eligibility, we selected a sample of 40 participants receiving meals at centers contracted with the CBS Food Program. For 2 of the 40 participants, management was unable to provide complete and valid eligibility documentation. In one instance, the only available eligibility form had been prepared in a future fiscal year, and in another instance, the eligibility form could not be located at all. Recommendation: We recommend that management strengthen its CACFP eligibility documentation procedures to ensure that all required forms are properly completed, collected, and retained for every participant. This should include implementing a standardized intake process, maintaining timely reviews to confirm completeness of eligibility files, and developing a tracking or monitoring system to identify missing or outdated documentation. Management should also reinforce internal expectations for timely updating of eligibility files and ensure staff are trained on CACFP documentation requirements. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: On February 1, 2025, Community Benefit Solutions rolled out the KidKare software system wide. KidKare is a CACFP software that allows Community Benefit Solutions to digitally process all eligibility-documentation, standardize the enrollment procedures, ensure forms are completed in accordance with the relevant regulations, request updated documentation upon the expiration of enrollment forms, and digitally store all the eligibility related information for all participants. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171919 (2024-004)

Material Weakness 2024

Community Benefit Solutions

PA

Allowable Costs / Cost Principles School Nutrition Programs Material Weakness § 200.303 § 200.430

2024-004 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-004 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition As part of our audit procedures, we selected a sample of 40 payroll transactions for review. This process included examination of employee human resource files (such as signed W-4 and I-9 forms), management-approved pay rates, time sheets with supervisory sign-off, and corresponding payroll reports. We recalculated total hours per timesheet using the employees' pay rates and compared these figures to the relevant payroll reports. During our review, we observed that two employees received additional compensation ranging from $25 to $75 for undertaking extra responsibilities related to the administration of the CBS Food Program’s Summer Food Service Program by the former Chief Executive Officer. Management was unable to provide supporting documentation evidencing approval by the former Chief Executive Officer or confirmation from the Commonwealth of Pennsylvania, Department of Education, indicating that such additional compensation complied with the contractual agreement governing the Summer Food Service Program. Additionally, of the 40 payroll transactions sampled, we noted one employee’s required payroll change documentation (e.g., an approved payroll change form) was not present in their personnel file. Recommendation We recommend that management improve internal controls for payroll authorization by making sure every payroll change form and supplemental compensation approval is filled out, approved, and kept on file. Introducing a central electronic document management system will help securely store records, standardize documentation, and create clear audit trails for all payroll and personnel files. Management should also regularly review payroll records to confirm that all necessary paperwork, such as personnel forms, pay rate approvals, and backup for extra pay, is included. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions repeats the actions to be taken in response to finding 2024-003 and adds the following: Community Benefit Solutions will utilize ADP document management capabilities to maintain employee files including, but not limited to, Payroll Change Forms or other documentation related to modifications or supplements to employee pay. Community Benefit Solutions will ensure complete upload of all paper files to the appropriate employee profile within ADP to ensure documentation can be readily accessible by those with necessary authorization. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171914 (2024-008)

Material Weakness 2024

Community Benefit Solutions

PA

School Nutrition Programs Subrecipient Monitoring Material Weakness § 200.327 § 200.328 § 200.334

2024-008 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of the reporting requirem...

2024-008 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of the reporting requirements for the CBS Food Program under the National School Lunch Program (NSLP) and Summer Food Service Program (SFSP), management is responsible for submitting the FNS 10 (NSLP) and FNS 418 (SFSP) reports within 30 days after month-end. However, management was unable to provide five (5) monthly NSLP reports and one (1) monthly SFSP report requested for audit testing. Recommendation: The Organization should establish and enforce strengthened internal controls over federal reporting to ensure that all required monthly reports (FNS 10 and FNS 418) are: (a) completed accurately, (b) submitted on time, and (c) retained in accordance with federal record retention requirements (2 CFR 200.334). Management should designate responsible personnel and implement a monitoring process to ensure compliance. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Effective, July 1, 2024, Community Benefit Solutions no longer administers the National School Lunch Program. In the event Community Benefit Solutions should begin administering the NSLP, Community Benefit Solutions will develop and implement requisite policies and procedures to ensure proper reporting requirements including, but not limited to, completion and submission of the FNS10. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171899 (2024-003)

Material Weakness 2024

City of Gloversville, New York

NY

Reporting Internal Control / Segregation of Duties § 200.510

The City will implement procedures to ensure accurate SEFA preparation

View Audit 384938

Finding 1171897 (2024-002)

Material Weakness 2024

City of Gloversville, New York

NY

Internal Control / Segregation of Duties § 200.512

The City intends to implement procedures to ensure timely account reconciliations which will facilitate timely audit submission.

View Audit 384938

Finding 1171896 (2024-001)

Material Weakness 2024

Town of Plaistow

NH

Procurement, Suspension & Debarment

Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The Town recognizes the need to follow the rules regarding suspension and debarment. Although, not formally, it was considered prior to awarding the contracts. In the future, before awarding/signing any contracts ...

Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The Town recognizes the need to follow the rules regarding suspension and debarment. Although, not formally, it was considered prior to awarding the contracts. In the future, before awarding/signing any contracts that involve Federal funds, care will be taken to ensure the requirement is met. Name of Contact Person and Completion Date: Name: Gregory A Colby, CPA – Town Manager/Finance Director Anticipated Completion Date – January 28, 2026

View Audit 384927

Finding 1171884 (2024-003)

Material Weakness 2024

Heart of Georgia Regional Airport Authority

GA

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

THE BOARD WILL DOCUMENT THE PROCUREMENT PROCEDURES FOR FEDERAL AWARDS AND SUBAWARDS.

View Audit 384866

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