Finding 1165233 (2025-003)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2025
Accepted
2025-12-17
Audit: 375620
Organization: Porter-Leath (TN)

AI Summary

  • Core Issue: Inaccurate eligibility classifications for meal reimbursements due to insufficient controls and manual errors.
  • Impacted Requirements: Non-compliance with 2 CFR 200.303 and OMB Compliance Supplement for CACFP regarding documentation and internal controls.
  • Recommended Follow-Up: Strengthen internal controls by ensuring documented verification of income and implementing a reconciliation process between application approvals and system entries.

Finding Text

2025-003 – Inaccurate Eligibility Classification and System Entry U.S. Department of Agriculture Child and Adult Care Food Program (CACFP) – AL #10.558 TN Department of Human Services Condition: We noted multiple instances in which eligibility determinations based on income levels, specifically related to rates at which student meals are reimbursed (paid, reduced, or free), lacked sufficient controls in place to categorize the student accurately. Criteria: Under 2 CFR 200.303, non-federal entities must establish and maintain effective internal control over federal programs to provide reasonable assurance of compliance with Federal statutes, regulations, and the terms and conditions of the award. The OMB Compliance Supplement for CACFP requires recipients to obtain, review, and retain sufficient documentation to verify participant eligilbility at the time eligibility is determined. Cause: Due to the process being heavily manual in nature, the deficiencies ultimately resulted from human error. Despite multiple levels of documented approvals of the application, the control failed as the different levels of review did not catch the participant being classified incorrectly based on income levels. Additionally, there is a lack of defined procedures to ensure that the approved documentation is reconciled with the eligibility category entered into the system, as there were instances where the student was classified correctly on the application form but not within the system. The errors affected both manual documentation review and data-entry classification, indicating a disconnect between approval and system processing. Effect: Due to the eligibility classifications being incorrect, the Organization was reimbursed at lower rates than supported by the documentation. As a result, the errors did not lead to overcharging the federal program, but instead, caused the Organization to claim less reimbursement than that for which it was eligible. Although this reduces the risk of questioned costs for overbillings, the conditions represent a control failure. Such control failures could lead to future noncompliance or incorrect claims in either direction if not addressed. Context: A sample of forty (40) students were selected for eligibility testing. Three (3) CACFP application forms were classified incorrectly as free, reduced, or paid based on income levels. Two (2) participants were entered into the system under the incorrect eligibility category, resulting in a discrepancy between the supporting documentation and the recorded classification. Recommendation: We recommend that management strengthen internal controls over the eligibility process. Management should retain the multi-level review structure; however, each level of review should include a documented verification of income information and eligibility categorization. In addition, management should implement a formal reconciliation process that confirms the eligibility classification approved on the application form matches the classification entered into the system prior to finalization or claim submission. Management’s Response: See accompanying management’s corrective action plan.

Corrective Action Plan

2025-003: Inaccurate Eligibility Classification and System Entry Issue: Eligibility classifications in CACFP were entered incorrectly due to manual processes and inconsistent verification. In some cases, the eligibility category recorded in the system did not match the approved paper application. Documentation of income verification and classification checks was incomplete or not retained. Corrective Actions: Porter-Leath will strengthen controls over eligibility determination by requiring a complete review of all eligibility documents before system entry. 1. Applications will first be checked by administrative or Family Services staff to verify household size, income documentation, and appropriate eligibility category. 2. Site Managers will review the classification for accuracy and ensure the approved determination is entered consistently into ChildPlus or ProCare. 3. A final review by the Preschool Coordinator will confirm that the eligibility classification on the application matches the classification stored in the system prior to claim submission. 4. A reconciliation step will be built into the monthly workflow so discrepancies between documentation and system data are identified and corrected promptly. Responsible Personnel: Family Services Liaisons, Site Administrative Staff, Site Managers, Preschool Coordinator, CACFP Coordinator Timeline: Revised procedures implemented within 15 days; staff training completed within 30 days. Monitoring: Periodic quarterly reviews of at least 25 percent of eligibility files will be conducted to confirm proper classification and system accuracy, with results reported to management.

Categories

Cash Management Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1165231 2025-001
    Material Weakness Repeat
  • 1165232 2025-002
    Material Weakness Repeat
  • 1165234 2025-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.600 HEAD START $7.75M
93.558 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES $2.93M
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $923,139
10.558 CHILD AND ADULT CARE FOOD PROGRAM $798,633
94.011 AMERICORPS SENIORS FOSTER GRANDPARENT PROGRAM (FGP) 94.011 $769,383
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $451,371
94.006 AMERICORPS STATE AND NATIONAL 94.006 $428,900
93.575 CHILD CARE AND DEVELOPMENT BLOCK GRANT $299,600
94.017 AMERICORPS SENIORS SENIOR DEMONSTRATION PROGRAM (FGP) 94.017 $258,473
10.555 NATIONAL SCHOOL LUNCH PROGRAM $3,107