8/29/2017 HOW TO PREPARE AN EFFECTIVE CORRECTIVE ACTION PLAN. MH Miles Company, CPA, PC. Your Presenters. MH Miles Company, CPA, PC

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1 HOW TO PREPARE AN EFFECTIVE CORRECTIVE ACTION PLAN 2017 Delaware Annual CACFP Training Tuesday, September 19, Niche Certified Public Accounting Firm Specialize In Governmental Compliance NUTRITION, TRANSPORTATION, EDUCATION MHMC s Services For State Agencies: *Monitoring & Program Outreach *Investigations *Audits / Agreed-upon Procedures Reviews *Staff Augmentation *Training & Consulting Services *FAR 31 Compliance *Cognizant Reviews *Indirect Cost Audits MH Miles Company, CPA, PC 2 Your Presenters Chloe Miles, MBA, CFE Susan Matthews, MBA, CFE MH Miles Company, CPA, PC 3 1

2 To understand where/why findings originate To change your approach to responding to findings To obtain a thorough understanding of how to draft an effective corrective action plan (CAP) Objectives 4 Administrative Reviews Occur at least once every 3 years Typically unannounced Includes review of CACFP records & observation of at least one meal or snack *Admin review may result in Findings which require follow-up and/or technical assistance reviews 5 What is a Finding? The determination of a question submitted. This could be a finding of fact (as in: the defendant was the one who robbed the bank) or a finding of law (as in: the defendants use of the copyrighted material was protected by the fair use doctrine). Depending on the circumstances, the finding can be an observation The results of an inquiry can be made by a judge or a jury. -Cornell University Law School- Legal Learning Institute 6 2

3 What is a Finding? Findings are areas of noncompliance with Federal regulations, the CFR, FNS Instructions, and CACFP policy memoranda; and require immediate attention. -USDA Monitoring Handbook for State Agencies 7 Where Findings Originate Federal Agency (USDA) State Agency State Agency Institution Institution Center DCH provider 8 How Does the Reviewer Develop a Finding? Criteria Condition Cause Effect MH Miles Company, CPA, PC 9 3

4 What is a Corrective Action Plan (CAP)? An adequate CAP must contain: What- what process and/or procedure will be implemented to correct the findings? (Detail) How- how will the institution ensure that the processes and/or procedures are followed consistently in order to prevent future findings? (Detail) 10 Corrective Action Plan (CAP) An adequate CAP must contain: Who- who is/are responsible for implementing & complying with the process and/or procedures? (Name & Title) When- when will the process and/or procedure be implemented? (Specific Date) 11 Common Finding Scenario On April 3, The reviewer observed that the center served bacon and apple juice for breakfast to the 1-12 year old age group. Finding The center failed to serve an adequate meal according to the CACFP meal pattern requirements found in 7 CFR (c). Reviewers observed that twenty-five 1-12 year old children were served bacon and apple juice on 4/3/2017. The required milk and bread components were not served to program participants. As a result, 25 breakfast meals must not be claimed for reimbursement by the facility. Required Action The center must ensure compliance with 7 CFR (c). Each meal claimed for reimbursement must have a corresponding menu that lists all required components. Only creditable meals should be claimed for reimbursement each month. 12 4

5 Potential Response (CAP) Finding: The center failed to serve an adequate meal according to the CACFP meal pattern requirements found in 7 CFR (c). Reviewers observed that twenty-five 1-12 year old children were served bacon and apple juice on 4/3/2017. The required milk and bread components were not served to program participants. As a result, 25 breakfast meals must not be claimed for reimbursement by the facility. Prepare a corrective action plan (What, How, Who & When must be considered) We will not serve bacon and apple juice for breakfast to 1-12 year old children. We will no longer purchase bacon or apple juice. Anyone that purchases bacon or apple juice will be fired immediately. This policy will be implemented immediately by the Center Director. 13 Adequate or Inadequate? CAP: We will not serve bacon and apple juice for breakfast to 1-12 year old children. We will no longer purchase bacon or apple juice. Anyone that purchases bacon or apple juice will be fired immediately. This policy will be implemented immediately by the Center Director. 14 an Effective CAP STEP 1- Read the Finding & Required Action Finding The center failed to serve an adequate meal according to the CACFP meal pattern requirements found in 7 CFR (c). Reviewers noted that twenty-five 1-12 year old children were served bacon and apple juice on 4/3/2017. The required milk and bread components were not served to program participants. As a result, 25 breakfast meals must not be claimed for reimbursement by the facility. Required Action The center must ensure compliance with 7 CFR (c). Each meal claimed for reimbursement must have a corresponding menu that lists all required components. Only creditable meals should be claimed for reimbursement each month 15 5

6 STEP 2- Look up the specific federal regulatory guidance, State memo or regulation cited in the finding. 7 CFR (c) Criteria surrounding meal patterns for ages 1-12 Criteria surrounding creditable components 16 7 CFR (c) Meal patterns for children age 1 through 18 and adult participants. Institutions and facilities must serve the food components and quantities specified in the following meal patterns for children and adult participants in order to qualify for reimbursement. (1)Breakfast. Fluid milk, vegetables or fruit, or portions of both, and grains are required components of the breakfast meal. Meat and meat alternates may be used to meet the entire grains requirement a maximum of three times per week. The minimum amounts of food components to be served at breakfast are as follows: -Cornell University Law School- Legal Learning Institute

7 STEP 3- Gather documentation referenced in the Finding (ex: IEFs, CACFP Attendance/Meal Count Sheets, menus, receipts, etc.). Next Assess where you went wrong & how to fix the problem. 19 STEP 4: Draft an outline for your corrective action plan 20 STEP 5- What, How, Who, When Time to Finalize your CAP! 21 7

8 Example #1 of an Effective Corrective Action Plan (CAP) WHAT/HOW: The Cook will be trained by the Executive Director regarding meal pattern requirements including components and quantities. A review of 7 CFR (c) and the CACFP Food Crediting Guide will be performed prior to developing cycle menus to ensure all meal components are included. The Executive Director will approve the cycle menus prior to food preparation. The cook will prepare food components in accordance with the approved cycle menus. The Executive Director will also review menus prior to submitting a claim for reimbursement to ensure compliance with applicable regulations. Meals will only be claimed for reimbursement in accordance with 7 CFR (c). WHO: Executive Director, Sally Smith & Cook, Donna Wright WHEN: May 1, Example #2 STEP 1- Read the Finding & Required Action Finding: Income eligibility is not correct, current, or complete for the review month (June 2017). Income Eligibility Statements are not current per 7 CFR (f) and/or complete per 7 CFR (e) (1) and 7 CFR (F) and/or correctly categorized per CFR (e)(4). Income eligibility was incorrectly determined for 20 program participants. The center misclassified income eligibility based on income (income miscalculations) for 7 participants. Correct 3 forms are expired (dated in 2015). Current 10 income eligibility forms are incomplete because the parents/guardians failed to sign the forms. Complete *As a result, the 20 children were reclassified to the Paid category by the State Agency reviewer. 23 STEP 1- Read the Finding & Required Action Required Action: The center must ensure compliance with 7 CFR (f), 7 CFR (e) (1), 7 CFR (F) and 7 CFR (e)(4). IEFs must be completed in their entirety (including parent/guardian signatures), and income must be correctly calculated so that program participants are properly classified as Free, Reduced or Paid. Additionally, IEFs must be updated annually so that income eligibility data is not expired. 24 8

9 STEP 2- Look up the specific federal regulatory guidance, State memo or regulation cited in the finding. CFR (e)(4)- Correct (4)Determination of eligibility. The institution shall take the income information provided by the household on the application and calculate the household s total current income. When a completed application furnished by a family indicates that the family meets the eligibility criteria for free or reduced-price meals, the participants from that family shall be determined eligible for free or reducedprice meals. -Cornell University Law School- Legal Learning Institute 25 STEP 2- Look up the specific federal regulatory guidance, State memo or regulation cited in the finding. 7 CFR (f)- Current (f) Free, reduced-price and paid meal eligibility figures must be reported by institutions to State agencies at least once each year and shall be based on current family-size and income information of enrolled participants. Such information shall be no more than 12 months old. -Cornell University Law School- Legal Learning Institute 26 STEP 2- Look up the specific federal regulatory guidance, State memo or regulation cited in the finding. 7 CFR (e) (1) and 7 CFR (F) -Complete Application for free and reduced-price meals the application for children shall contain a request for the following information The signature of an adult member of the household which appears immediately below a statement that the person signing the application certifies that all information furnished is true and correct -Cornell University Law School- Legal Learning Institute 27 9

10 28 an Effective CAP STEP 4- Draft an Outline for your CAP 3 IEF issues (not correct, current, complete) 29 STEP 5: WHAT/HOW: The Center Director and Administrator will review the federal regulations cited in the Finding. A refresher training (review of IEF requirements) will be facilitated by the Director & attended by the Administrator and Lead Teachers. Correct: The Director will obtain the center s IEF Binder and pull the current Income Eligibility Guidelines from DDOE s website. Each IEF will be thoroughly reviewed (SNAP/TANF Case Numbers will be checked, income will be recalculated, etc.) by the Director to ensure each child is correctly categorized as Free, Reduced or Paid. Children incorrectly classified will be moved to the correct category and the Director will initial change(s) made to the form. Complete: The Center Director will review the Center s IEF Binder and pull the forms that are missing required information (parent signatures, Social Security Number or Check if No SSN, etc.). The forms will be set aside, tagged, and the statements will be given to the Lead Teacher, who will then obtain the missing information from the parent/guardian at the child s pick-up time. The Director will place the child in the Paid category until a completed IEF is on file. Current: The Director will pull expired IEFs from the IEF Binder and set the forms aside. New forms will be given to the Lead Teacher, who will then request that the IEF be promptly completed and returned to the facility the following day (forms will be submitted to the Center Director). The Director will place the child in the Paid category until a current IEF is on file. *All IEFs will be reviewed by the Center Director (once per month and upon enrollment) to ensure that IEFs on file are not expired, correctly categorized, and that all required information is documented for each child. A secondary review will also be performed by the Administrator. Parents of newly enrolled participants will be provided with an IEF upon registration and will be asked to complete & submit the form before the program participant attends the facility. However, if a form is not provided for the newly enrolled child, the Director will place the participant in the paid category until an IEF is on file

11 STEP 5: WHO: Sally Smith, Center Director Kim Simms, Administrator Sharon Stone, Cameron Wright & Leah Harris, Lead Teachers WHEN: September 1, Activity Now It s Your Turn! 32 Draft for the Finding: Finding: In accordance with 7 CFR (e)(4), each institution shall establish procedures to collect and maintain all required program records. The childcare center did not report an accurate attendance count for the month under review (August 2017). Upon validation of attendance counts, the State Agency reviewer counted less attendance than what was claimed by the center. The child care center claimed a monthly attendance of 800, while the State Agency reviewer verified an attendance of 310 children for August Required Action: The organization must be in compliance with 7 CFR (e)(4). The center must maintain and submit accurate attendance counts. Manual attendance counts may need to be double checked by an additional administrator

12 QUESTIONS 34 Thank you!! Contact Information: Susan Chloe (404)

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