Corrective Action Plans

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Incorrect Grant Drawdown - Allowable Costs/Reporting - Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding: Material Weakness in Internal Control Over Compliance Cause: Controls designed to ensure grant expenditures were properly aligned with the correct ...
Incorrect Grant Drawdown - Allowable Costs/Reporting - Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding: Material Weakness in Internal Control Over Compliance Cause: Controls designed to ensure grant expenditures were properly aligned with the correct federal award prior to drawdown were not operating effectively, and procedures for identifying, reporting, and correcting drawdown errors were not consistently applied. Corrective Actions: 1. Strengthen internal controls over grant drawdowns by implementing procedures to ensure expenditures are reviewed and reconciled to the appropriate federal award prior to requesting funds. Management should also establish formal procedures for timely identification, documentation, and communication of drawdown errors to the awarding agency when identified.
Untimely Submission of Federal Financial Reports (SF 425) - Reporting - Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding - Significant Deficiency in Internal Control Over Compliance Cause - Controls and procedures designed to ensure timely preparation,...
Untimely Submission of Federal Financial Reports (SF 425) - Reporting - Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding - Significant Deficiency in Internal Control Over Compliance Cause - Controls and procedures designed to ensure timely preparation, review, and submission of required federal financial reports were not consistently followed, resulting in delayed submission of SF-425 reports. Corrective Actions: 1. Improvement of Data Entry and Documentation Management: a. The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. b. Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: a. A regular internal review and audit process will be revisited to ensure that backup, storage and retention practices are followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. b. Any discrepancies or issues identified during audits will be addressed promptly, and corrective action will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: a. Training sessions will be conducted for all relevant staff on the updated backup, storage and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. b. Refresher training will be provided quarterly to ensure ongoing compliance and awareness.
The chief finance officer will reconcile FSR submission to document support and the general ledger before submission.
The chief finance officer will reconcile FSR submission to document support and the general ledger before submission.
The chief financial officer will compare the FSR to the grant before submission.
The chief financial officer will compare the FSR to the grant before submission.
The chief financial officer will compare the FSR to the grant before submission.
The chief financial officer will compare the FSR to the grant before submission.
The assistant finance officer will reconcile invoices to the amount of the federal award. The chief finance officer will review and submit the FSR for approval.
The assistant finance officer will reconcile invoices to the amount of the federal award. The chief finance officer will review and submit the FSR for approval.
Bill.com is the system being used to approve disbursements and maintain an audit trail.
Bill.com is the system being used to approve disbursements and maintain an audit trail.
A process has been put in place where we use bill.com to keep all backup documentation for expenditures. The backup documentation is entered with the invoice for payment.
A process has been put in place where we use bill.com to keep all backup documentation for expenditures. The backup documentation is entered with the invoice for payment.
Corrective Action: The Foundation acknowledges that the 2024 single audit reporting package was not submitted by the September 30, 2025 deadline under 2 CFR 200.512. This delay resulted directly from the challenges detailed in Finding 2024-001. Significant accounting turnover delayed year-end reconc...
Corrective Action: The Foundation acknowledges that the 2024 single audit reporting package was not submitted by the September 30, 2025 deadline under 2 CFR 200.512. This delay resulted directly from the challenges detailed in Finding 2024-001. Significant accounting turnover delayed year-end reconciliations and SEFA preparation. The Foundation has implemented substantial corrective actions to address root causes and ensure future timeliness. As outlined in the response to Finding 2024-001, comprehensive SOPs now govern financial close, revenue/deposit processing, reconciliations, payroll, fiscal sponsorship financial management, and fund setup. These promote consistent monthly GL reconciliations, accurate/timely transaction recording, strong documentation, and efficient inter-departmental coordination. Supporting improvements include standardized monthly reporting, system integrations reducing manual work, clear responsibilities and timelines in SOPs, and emphasis on procedural continuity to mitigate transition risks. The Foundation is completing remaining 2024 items and committed to submitting the package promptly. With the enhanced control environment, the 2025 close and audit will be completed well within required timelines. Ongoing training, procedure reviews, and oversight by the Finance Director and Fiscal Sponsorship Manager will sustain compliance. By these actions, the Foundation has remediated the conditions and is positioned to meet all future single audit deadlines while maintaining strong fund stewardship. Person Responsible: Justin O’Shea, Finance Director Completion Date: Corrective action was completed as of December 31, 2025
February 2, 2026 Person responsible: Diane Spann, Executive Director Fiscal Year Ended June 30, 2024 Section III – Federal Awards Findings and Questioned Costs Item 2024 – 001 Federal Assistance Listing Number: 93.600 Head Start Condition The Organization’s Data Collection Form submission to the Fed...
February 2, 2026 Person responsible: Diane Spann, Executive Director Fiscal Year Ended June 30, 2024 Section III – Federal Awards Findings and Questioned Costs Item 2024 – 001 Federal Assistance Listing Number: 93.600 Head Start Condition The Organization’s Data Collection Form submission to the Federal Audit Clearinghouse was not filed on time within nine months of the end of its fiscal year. Views of Responsible Officials and Corrective Action Additional time was needed to complete accurate fiscal records for the year ended June 30, 2024. The Data Collection form for the year ended June 30, 2024 will be submitted as soon as the financial statements has been finalized.
Views of responsible officials and planned corrective actions - Management concurs with the audit findings and plans to review and implement additional internal policies and procedures related to procurement and suspension and debarment protocols for grant funding in future periods.
Views of responsible officials and planned corrective actions - Management concurs with the audit findings and plans to review and implement additional internal policies and procedures related to procurement and suspension and debarment protocols for grant funding in future periods.
Finding 1220081 (2024-005)
Material Weakness 2024
FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Burzynski Thaddeus Contact Phone Number and Email Address: 219-755-3200, burzytx@lakecountyin.org Views of Responsible Officials: We concur wit...
FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Burzynski Thaddeus Contact Phone Number and Email Address: 219-755-3200, burzytx@lakecountyin.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The County will develop and implement a proper system of internal controls and segregation of duties. This will ensure accuracy and correctness of all quarterly P & E Reports in the future. Anticipated Completion Date: December 2026
Finding 1220080 (2024-004)
Material Weakness 2024
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Burzynski Thaddeus Contact Phone Number and Email Address: 219-755-3200, burzytx@lakecountyin.org Views of Respo...
FINDING 2024-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Burzynski Thaddeus Contact Phone Number and Email Address: 219-755-3200, burzytx@lakecountyin.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: As this finding is shared between The Lake County Board of Commissioners and the Lake County Parks & Recreation Department, both departments will develop procedures to ensure the appropriate procurement methods are used for vendors that are within the Small Purchase Threshold. Both departments will also ensure that vendors are not suspended or debarred when expanding federal funds. Lastly, appropriate documentation will be maintained to ensure compliance with procurement, suspension and debarment in the future. Anticipated Completion Date: December 2026
Finding 1220078 (2024-003)
Material Weakness 2024
FINDING 2024-003 Finding Subject: Highway Planning and Construction - Equipment and Real Property Management Contact Person Responsible for Corrective Action: Craig Zandstra Contact Phone Number and Email Address: 219-945-0543 Ext 234, craigz@lakecountyparks.com Views of Responsible Officials: We co...
FINDING 2024-003 Finding Subject: Highway Planning and Construction - Equipment and Real Property Management Contact Person Responsible for Corrective Action: Craig Zandstra Contact Phone Number and Email Address: 219-945-0543 Ext 234, craigz@lakecountyparks.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will implement a process of better tracking of asset purchases paid with the Highway Planning and Construction grant. Will ensure that the list is updated every year. Anticipated Completion Date: December 2026
Recommendations: Management should implement procedures to ensure that all payroll-related costs, including bonuses and stipends, are properly classified within the accounting system. Management should also establish review controls over coding of expenditures to ensure consistency with Uniform Guid...
Recommendations: Management should implement procedures to ensure that all payroll-related costs, including bonuses and stipends, are properly classified within the accounting system. Management should also establish review controls over coding of expenditures to ensure consistency with Uniform Guidance and grant reporting requirements. Views of responsible officials and planned corrective actions: Management agrees with the finding and indicates that it will strengthen review procedures over expense classification and ensure that compensation costs are properly recorded within payroll-related accounts going forward. Anticipated Completion Date: September 30, 2026
Recommendations: Management should discontinue charging rent equivalents or mortgage payment amounts to federal programs for owned facilities. Going forward, management should charge allowable facility costs using depreciation, computed in accordance with Uniform Guidance and properly allocated to b...
Recommendations: Management should discontinue charging rent equivalents or mortgage payment amounts to federal programs for owned facilities. Going forward, management should charge allowable facility costs using depreciation, computed in accordance with Uniform Guidance and properly allocated to benefiting programs. Management should also ensure that any interest costs charged to federal awards, if any, are specifically allowable under Uniform Guidance and the terms of the award and are supported by appropriate documentation and approvals. Views of responsible officials and planned corrective actions: Management acknowledged the finding and stated that the occupancy charges were intended to recover facility costs incurred in operating the federal program. Management indicated that policies and procedures will be updated to ensure compliance with Uniform Guidance requirements for charging facility costs to federal awards. Anticipated Completion Date: September 30, 2026
Recommendations: Management should implement procedures to review all non-routine or capital-related expenditures for allowability and compliance with grant terms prior to charging such costs to federal awards, including obtaining required approvals where applicable. Views of responsible officials a...
Recommendations: Management should implement procedures to review all non-routine or capital-related expenditures for allowability and compliance with grant terms prior to charging such costs to federal awards, including obtaining required approvals where applicable. Views of responsible officials and planned corrective actions: Management agrees with the finding and indicates that it will implement additional review procedures to ensure that all expenditures charged to federal programs are evaluated for allowability and properly approved prior to being incurred. Anticipated Completion Date: September 30, 2026
Recommendations: Management should establish formal procedures requiring documented authorization for all disbursements and ensure that such approvals are retained in an organized and accessible manner. Additionally, the Organization should implement procedures requiring formal documentation of empl...
Recommendations: Management should establish formal procedures requiring documented authorization for all disbursements and ensure that such approvals are retained in an organized and accessible manner. Additionally, the Organization should implement procedures requiring formal documentation of employee compensation arrangements, including established pay rates, and ensure that this documentation is consistently maintained and readily available for audit and compliance purposes. Views of responsible officials and planned corrective actions: Management agrees with the finding and indicates that it will implement formal approval procedures requiring documented authorization for all disbursements and will retain such documentation within its accounting records. Management also plans to implement standardized employment agreements and compensation authorization documentation for all employees and strengthen document retention practices to ensure compliance with federal requirements. Anticipated Completion Date: September 30, 2026
Recommendations: Management should implement compensating controls to address the lack of segregation of duties, such as enhanced and documented review of disbursements and financial activity by an independent member of the Board of Directors, including periodic review of detailed financial reports,...
Recommendations: Management should implement compensating controls to address the lack of segregation of duties, such as enhanced and documented review of disbursements and financial activity by an independent member of the Board of Directors, including periodic review of detailed financial reports, bank reconciliations, and supporting documentation. Views of responsible officials and planned corrective actions: Management agrees with the finding and indicates that, due to limited staffing, complete segregation of duties is not feasible; however, it will strengthen compensating controls by increasing the level of Board oversight and implementing more formalized review and approval procedures over financial activity. Anticipated Completion Date: December 31, 2026
Recommendations: Management should implement a financial reporting process that includes maintaining a complete general ledger and trial balance, recording all balance sheet accounts, and preparing complete financial statements and disclosures on a periodic basis. Management should establish review ...
Recommendations: Management should implement a financial reporting process that includes maintaining a complete general ledger and trial balance, recording all balance sheet accounts, and preparing complete financial statements and disclosures on a periodic basis. Management should establish review procedures to ensure the accuracy and completeness of financial reporting, whether performed internally or with the assistance of external accountants. In addition, management should implement formal policies and procedures requiring the preparation, approval, and retention of complete Board meeting minutes for all meetings, as well as the retention of supporting documentation for significant estimates and transactions, including compensation decisions and bonus determinations, to ensure that all amounts recorded in the financial statements are adequately supported. Views of responsible officials and planned corrective actions: Management agrees with the finding and acknowledges the limitations of its current financial reporting and documentation practices. Management indicates it will evaluate options to improve its accounting system and financial reporting capabilities, strengthen review procedures over financial statements prepared by external accountants, and implement policies to ensure that Board meeting minutes and supporting documentation for compensation decisions are properly maintained going forward. Anticipated Completion Date: September 30, 2026
management has implemented a monitoring system to ensure earlier coordination with auditors and timely filing going forward.
management has implemented a monitoring system to ensure earlier coordination with auditors and timely filing going forward.
Management will ensure that all rental arrangements are supported by executed lease agreements and that such documentation is retained in accordance with federal recordkeeping requirements
Management will ensure that all rental arrangements are supported by executed lease agreements and that such documentation is retained in accordance with federal recordkeeping requirements
To remediate this weakness and strengthen financial reporting, management will implement the following: 1. Monthly Close & Reconciliation Calendar – Establish a documented month-end close checklist with due dates and owners for all key reconciliations (cash, A/R, A/P, payroll liabilities, grants/gra...
To remediate this weakness and strengthen financial reporting, management will implement the following: 1. Monthly Close & Reconciliation Calendar – Establish a documented month-end close checklist with due dates and owners for all key reconciliations (cash, A/R, A/P, payroll liabilities, grants/grant receivables, fixed assets, debt, accrued expenses). 2. Trial Balance–to–GL Tie-Out – Implement a standardized tie-out package requiring each balancesheet account to be supported by a reconciliation that agrees to the detailed GL and the trial balance; variances >$0 must be researched and resolved before closing. 3. Document Standards – Adopt minimum documentation requirements (e.g., bank statements, reconciliations, inventory roll-forwards, grant schedules, amortization/support for accruals) and a centralized digital filing structure to ensure audit-ready support. 4. Adjusting Entry Controls – Require preparer/reviewer sign-off for all journal entries, with written support attached (calculation, source documents) and a monthly summary review by the CFO. 5. Grants & Receivables Subledger – Implement (or remediate) a grants/AR subledger that agrees monthly to the GL, including aging, award mapping, and reconciliation to external funder reports. 6. Training & Accountability – Provide training to finance staff on the close checklist, reconciliation standards, and documentation requirements; performance goals will include timely, accurate completion of assigned reconciliations. 7. Oversight & Governance – Provide the Audit/Finance Committee with a monthly close status report (checklist completion, unreconciled items, and corrective items) until the weakness is fully remediated. 8. Transitional Support – Engage temporary external accounting support, as needed, to clear priorperiod backlogs and to assist with initial implementation of the close process.
Management has implemented procedures to ensure that prior to the disposition or sale of surplus assets identified as federally funded, the Parish will request disposition instructions from the federal awarding agency as required by 2 CFR 200.313(e).
Management has implemented procedures to ensure that prior to the disposition or sale of surplus assets identified as federally funded, the Parish will request disposition instructions from the federal awarding agency as required by 2 CFR 200.313(e).
Implement procedures and processes to ensure that the audit is completed timely.
Implement procedures and processes to ensure that the audit is completed timely.
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