On this page, you’ll find common Administrative Review findings and examples of how to respond with an effective Corrective Action.
You’ll see what kind of information to include, how to explain your actions, and supporting docs to attach.
Need further assistance with your corrective action plan? Our CACFP Solutions team is always here to help you implement successful systems and processes, including Corrective Actions!
Example 1: Missing Receipts for Food Purchases
Finding:
Receipts for food purchases made during the test month (October 2023) were missing for several transactions, resulting in unsupported expenses.
Root Cause:
Receipts were misplaced because there was no standardized system for collecting, storing, and reviewing documentation. Staff were not regularly trained on the necessity of maintaining original receipts for CACFP, and turnover led to gaps in knowledge.
Corrective Action:
- Immediate Audit: Conducted an internal audit of all food purchases from October 2023. Located 9 out of 11 missing receipts by contacting vendors and reviewing electronic purchase histories.
- Documentation Submission: All located receipts were scanned and submitted with this CAP. For the two receipts that could not be found, an affidavit of lost documentation was prepared and submitted as outlined in CACFP policy.
- Staff Training: On November 15, 2023, all staff involved in purchasing and recordkeeping attended a mandatory training session on CACFP documentation requirements. The session included:
- Step-by-step instructions for uploading receipts to the CACFP Receipts APP immediately after each purchase.
- Review of TDA requirements for documentation retention.
- Practice scenarios for handling lost or damaged receipts.
- Policy Update: Developed and distributed a written SOP (Standard Operating Procedure) for receipt management, including:
- Immediate photo upload of every receipt after purchase
- Weekly reconciliation of receipts by office manager
- Monthly administrative review of all documentation by Program Director
Preventive Measures:
- Implemented a digital receipt log using CACFP Receipts, with access given to all relevant staff.
- Scheduled monthly internal documentation reviews by the Program Director, with corrective feedback provided if any receipt is missing or illegible.
- Added a quarterly refresher training on documentation procedures to the annual training calendar.
- Updated employee onboarding materials to include receipt management expectations.
Responsible Person:
Lisa Tran, Office Manager
Supporting Documentation:
- Scanned copies of located receipts
- Affidavit of lost receipts
- Training agenda and signed attendance sheet
- Copy of new SOP
- Screenshot of digital receipt log
Example 2: Meal Counts Do Not Match Attendance Records
Finding:
Meal count records for the test month (September 2023) did not match daily attendance records. For five days, more meals were claimed than children in attendance.
Root Cause:
Meal counts were not recorded at the point of service. Instead, staff filled in counts at the end of each day from memory, leading to over-claiming. There was no process for cross-checking meal counts with attendance, and staff were not adequately trained on this CACFP requirement.
Corrective Action:
- Error Identification: Program Director reviewed all meal count and attendance records for the past three months, identifying the scope of the issue and ensuring all over-claims were corrected in subsequent reports to TDA.
- Process Change: Effective October 2, 2023, all classrooms are now required to record meal counts in the MyFoodCloud software at the time each meal is served. Staff may not fill in counts after meal service.
- Staff Retraining: On September 28, 2023, all teaching and kitchen staff completed hands-on retraining focused on:
- The importance of point-of-service meal counting
- How to use the digital system correctly
- Daily cross-check procedures with attendance logs
- Daily Review: The Program Director reviews both meal count and attendance records at the end of each day. Any discrepancies are addressed with staff before submission.
- Corrective Reporting: Any over-claimed meals from the review period were reported to TDA, and reimbursement was adjusted accordingly.
Preventive Measures:
- Established a written process for daily completion and review of meal count and attendance records.
- Added a monthly audit by the Program Director to verify records and provide staff feedback.
- Point-of-service meal counting training is now part of new employee orientation and biannual refresher trainings.
- Implemented a “double-sign off” process, where both the classroom teacher and Program Director confirm meal count accuracy.
Responsible Person:
Monica Rivera, Program Director
Supporting Documentation:
- Attendance and meal count logs for October 2023
- Training materials and attendance sheet
- Checklist and new SOP for daily record review
- Copies of corrective reports sent to TDA
Example 3: Outdated Income Eligibility Forms (IEFs)
Finding:
Several Income Eligibility Forms (IEFs) on file for enrolled participants had expired prior to the test month.
Root Cause:
There was no tracking system for expiration dates of IEFs, and some staff were unaware that forms must be updated annually.
Corrective Action:
- Immediate Update: Contacted all affected families and collected new IEFs for every participant with an expired form as of December 1, 2023.
- Review of Records: Audited all participant files to ensure all IEFs were current and signed by both parent and staff.
- Staff Training: Administrative staff attended a targeted training on eligibility requirements and best practices for collecting and tracking IEFs, including hands-on practice using the new tracking spreadsheet.
- Parent Communication: Developed and sent a letter to parents explaining the need for annual renewal and outlining the timeline for future renewals.
Preventive Measures:
- Implemented a digital CACFP software, MyFoodcloud, to monitor IEF expiration dates and send automated reminders 30 days in advance.
- Added a monthly file review of all participant eligibility forms by the CACFP Coordinator.
- Annual training for staff on eligibility and documentation requirements.
- IEF renewal is now included in the center’s annual compliance calendar.
Responsible Person:
David Nguyen, CACFP Coordinator
Supporting Documentation:
- Copies of new, completed IEFs
- Screenshot of tracking spreadsheet with reminder dates
- Staff training materials and sign-in sheet
- Sample parent renewal letter
Example 4: Incomplete Production Records
Finding:
Production records for lunch service during the test month (August 2023) were incomplete and missing required details such as portion sizes and menu items.
Root Cause:
Kitchen staff were using an outdated production record form that did not include fields for all required information. There had been no formal training on CACFP production record requirements.
Corrective Action (In Depth):
- Form Revision: Replaced the old production record form with a new, digitized TDA-compliant version via CACFP Software, MyFoodCloud, that includes required fields for menu items, portion sizes, and quantities prepared and served.
- Training: On September 10, 2023, kitchen staff and supervisors attended a workshop on accurately completing production records, with live demonstrations and practice sessions.
- Record Audit: The Program Director reviewed all production records from the past six months, identified missing information, and retroactively completed records when possible, attaching explanations for any gaps.
- Ongoing Support: Created a “cheat sheet” for kitchen staff summarizing required fields and common mistakes, posted in the kitchen area.
Preventive Measures:
- Weekly digital review of production records by the Program Director, with direct feedback to staff.
- Quarterly refresher training for all kitchen staff on production record requirements.
Responsible Person:
Sarah Williams, Program Director
Supporting Documentation:
- Copies of new and corrected production records
- New production record digital template
- Kitchen staff training agenda and sign-in sheet
- Production record cheat sheet