Corrective Action Plans

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Finding 1179667 (2023-004)
Material Weakness 2023
FINDING 2023-004 Contact Person Responsible for Corrective Action: Craig Zandstra Contact Phone Number: 219-945-0543 Ext 234 Contact Email: craigz@lakecountyparks.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan As this finding is shared between T...
FINDING 2023-004 Contact Person Responsible for Corrective Action: Craig Zandstra Contact Phone Number: 219-945-0543 Ext 234 Contact Email: craigz@lakecountyparks.com 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. Completion Date: June 2026
Finding 1179665 (2023-003)
Material Weakness 2023
FINDING 2023-003 Finding Subject: COVID-19 Emergency Rental Assistance Program - Period of Performance Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the f...
FINDING 2023-003 Finding Subject: COVID-19 Emergency Rental Assistance Program - Period of Performance Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding with reservations on a portion of the Finding. Description of Corrective Action Plan: \ This program is completed and the period of performance is over therefore there is not a need to formally adopt any Corrective Action Plan. The Subrecipient Contractor that administered the program has agreed that this finding was due to their internal error in submitting administration invoices too late to be properly processed and approved by the County. They will be reimbursing the ERA1 fund for the error in the amount of $154,812.56 that will be sent back to the US Treasury. Reservation: The US Treasury required the local grant recipient to prosecute ERA1 fraud activities. There were two fraud cases that were prosecuted by our local attorney. His fees were then deducted from the ERA1 fund as administration costs. The grant recipient should not be penalized for doing as directed to prosecute fraud cases without being able to pay for the services rendered. We do not control the timelines of the local courts nor the responses/actions of the defendants delaying the actions beyond the Period of Performance. Anticipated Completion Date: None, no corrective action plan is necessary.
Finding 1179664 (2023-002)
Material Weakness 2023
FINDING 2023-002 Finding Subject: CDBG - Entitlement Grants Cluster - Program Income Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding. Descriptio...
FINDING 2023-002 Finding Subject: CDBG - Entitlement Grants Cluster - Program Income Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: This same finding was part of the 2022 audit in Finding 2022-003. The department was aware that this same finding would be arising in the 2023 audit again due to multiple year errors of previous staff. The corrective action plan proposed and adopted as part of the Corrective Action Plan for finding 2022-003 is still in force and is working to eliminate such findings in the future. The Lake County Redevelopment Commission adopted Resolution 001-2025 on January 16th, 2025 amending the Policy and Procedures Manual of the Department concerning Program Income (PI) internal controls for proper reporting in the IDIS system to address and correct the finding going forward. Anticipated Completion Date: Done
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Assistance Listing Number: 93.498 Finding Summary: The Organization’s special reports submitted to the Department of Health and Human Services (H...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Assistance Listing Number: 93.498 Finding Summary: The Organization’s special reports submitted to the Department of Health and Human Services (HHS) for Period 5 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Stephanie Schmidt Corrective Action Plan: Before future reports are submitted to the federal agency, documented approval of this submission will be acquired. Anticipated Completion Date: January 2025
Cause: While policies were in place, detailed written procedures for consistent grant administration had not been developed or formally documented. Corrective Action Taken: A procedure manual has been written to incorporate required compliance areas, including allowability of costs, procurement, equ...
Cause: While policies were in place, detailed written procedures for consistent grant administration had not been developed or formally documented. Corrective Action Taken: A procedure manual has been written to incorporate required compliance areas, including allowability of costs, procurement, equipment management, cash management, time and effort reporting, suspension and debarment, and record retention. Planned Corrective Actions / Preventive Measures: 1. Procedure Development: Document clear written procedures including requisitioning, approvals, reimbursements, reporting, and monitoring. 2. Training and Implementation: Provide training to all staff involved in grant administration on the new procedures. Establish a schedule for periodic refresher training and updates when regulations or program requirements change. 3. Ongoing Monitoring: Designate the Business Administrator (or designee) to monitor compliance and review procedures annually. Update policies and procedures as needed to reflect changes in federal requirements or internal practices. Timeline: Procedures completed: September 2024. Staff training and implementation: June 2026. Ongoing monitoring: Annually, beginning March 2026 Responsible Parties: Lori Schmidt, Business Administrator: Oversight of policy and procedure revision, implementation, and monitoring. Scott LaFortune, Finance Manager/Grant Manager: Day-to-day adherence to procedures and reporting. School Board: Formal policy approval.
Cause: We were not able to meet reporting responsibilities in a timely manner during a period high personnel turnover which resulted in missed reconciliations and incomplete documentation. Corrective Action Taken: Monthly reconciliations and timely filing of required reports have been reinstated. Su...
Cause: We were not able to meet reporting responsibilities in a timely manner during a period high personnel turnover which resulted in missed reconciliations and incomplete documentation. Corrective Action Taken: Monthly reconciliations and timely filing of required reports have been reinstated. Supporting documentation is now reviewed and filed as part of the monthly process. Multiple staff members are involved in the reporting and reconciliation process to provide oversight and ensure continuity. Preventive Measures: Cross-training has been implemented so that multiple staff members can complete required tasks. Internal controls have been enhanced with supervisory review to ensure ongoing compliance with federal requirements. Responsible Parties: Lori Schmidt, Business Administrator and Scott LaFortune, Grant Manager are responsible for monitoring and ensuring continued compliance. Anticipated Completion Date: June 30, 2025
Improvements in SEFA preparation have been implemented in order to ensure accuracy.
Improvements in SEFA preparation have been implemented in order to ensure accuracy.
The Project has procedures in place to process payroll. The Project will review procedures to ensure ● filing deadlines are scheduled for each operating year in advance ● designated individuals are responsible for preparing, reviewing, and transmitting payroll data to the outside payroll agent for p...
The Project has procedures in place to process payroll. The Project will review procedures to ensure ● filing deadlines are scheduled for each operating year in advance ● designated individuals are responsible for preparing, reviewing, and transmitting payroll data to the outside payroll agent for processing ● outside payroll agent processes payroll and payroll tax returns properly and timely ● payroll obligations are paid timely ● payroll reports are timely received for each payroll period ● reconciliations are prepared each period
The Project will implement procedures to ensure year-end review of vendor transactions that require Form 1099 filings. The Project will prepare and file forms in compliance with governmental laws and regulations.
The Project will implement procedures to ensure year-end review of vendor transactions that require Form 1099 filings. The Project will prepare and file forms in compliance with governmental laws and regulations.
The Project has procedures in place to record transactions in accordance with HUD requirements. The Project will ensure that all procedures are followed to authorize, maintain, accurately record, and cancel vendor invoices.
The Project has procedures in place to record transactions in accordance with HUD requirements. The Project will ensure that all procedures are followed to authorize, maintain, accurately record, and cancel vendor invoices.
The Project has procedures in place for move-out inspections in compliance with HUD requirements. Information collected is documented, signed by the tenant and Project Manager, and retained in file as appropriate. The Project will ensure that procedures are followed and that supporting documentation...
The Project has procedures in place for move-out inspections in compliance with HUD requirements. Information collected is documented, signed by the tenant and Project Manager, and retained in file as appropriate. The Project will ensure that procedures are followed and that supporting documentation is filed appropriately.
The Project has procedures in place to certify prospective tenants and to recertify existing tenant eligibility in compliance with HUD requirements. Required documentation is collected and processed in the property management system. The documentation is retained in related files as applicable. The ...
The Project has procedures in place to certify prospective tenants and to recertify existing tenant eligibility in compliance with HUD requirements. Required documentation is collected and processed in the property management system. The documentation is retained in related files as applicable. The Project will ensure that information is documented in the appropriate system, documents are accurately generated, and that all supporting documentation is retained in related files as appropriate.
The Project has procedures in place to sign into the EIV System monthly and print the reports of: • Multiple subsidy • Identity verification • Deceased tenants • New hires
The Project has procedures in place to sign into the EIV System monthly and print the reports of: • Multiple subsidy • Identity verification • Deceased tenants • New hires
The Project will implement a procedure to review its coverage annually to align with the grantor contract notification of gross rent income projection. The current year’s insurance policy will be adjusted to reflect appropriate coverage. The Project reviewed its policies in successive years to incre...
The Project will implement a procedure to review its coverage annually to align with the grantor contract notification of gross rent income projection. The current year’s insurance policy will be adjusted to reflect appropriate coverage. The Project reviewed its policies in successive years to increase coverage. As a result, coverage was increased to $151,000 in January 2024 and the required coverage (two times gross revenue total) was met in July 2024.
The Project has ensured that internal controls are being followed. It has trained new staff to process payroll in accordance with its procedures. Payroll is now transmitted by an outside management agent.
The Project has ensured that internal controls are being followed. It has trained new staff to process payroll in accordance with its procedures. Payroll is now transmitted by an outside management agent.
The Project will contact HUD to discuss favorable remedies to resolve the issues. Procedures related to authorization have been enhanced to ensure that transactions entered into by the Project are allowable. The Project will ensure that all parties that authorize and process transactions have a work...
The Project will contact HUD to discuss favorable remedies to resolve the issues. Procedures related to authorization have been enhanced to ensure that transactions entered into by the Project are allowable. The Project will ensure that all parties that authorize and process transactions have a working knowledge of allowable vs unallowable costs.
The Project will contact HUD and SBA to discuss favorable remedies to resolve the issues. Procedures related to authorization have been enhanced to ensure that transactions entered into by the Project are allowable.
The Project will contact HUD and SBA to discuss favorable remedies to resolve the issues. Procedures related to authorization have been enhanced to ensure that transactions entered into by the Project are allowable.
The Project has procedures in place to record vendor transactions in the period incurred. The Project will maintain its financial statements on the accrual basis of accounting in accordance with Generally Accepted Accounting Principles (GAAP). The Project will utilize the accounts payable module to ...
The Project has procedures in place to record vendor transactions in the period incurred. The Project will maintain its financial statements on the accrual basis of accounting in accordance with Generally Accepted Accounting Principles (GAAP). The Project will utilize the accounts payable module to record invoices and obligations as incurred and will establish recurring and standard journal entries for routine accruals as applicable.
The Project has procedures in place to record transactions in the Financial Statements that identify sources and are traceable to assigned accounts. The Project will ensure that all transactions are appropriately posted. The Project transitioned to a new accounting software application during the mo...
The Project has procedures in place to record transactions in the Financial Statements that identify sources and are traceable to assigned accounts. The Project will ensure that all transactions are appropriately posted. The Project transitioned to a new accounting software application during the months of January 2023 through August 2023 and processed financial transactions in parallel software applications during the period. Transactions were recorded in batch into the new software application and were supported by a manual disbursement log, present for the audit.
Recommendation: We recommend the County implement a countywide system to allow for a more automated system of tracking federal expenditures, that may include updated processes to be developed to set up new organization codes which would require grant managers to provide the required information need...
Recommendation: We recommend the County implement a countywide system to allow for a more automated system of tracking federal expenditures, that may include updated processes to be developed to set up new organization codes which would require grant managers to provide the required information needed for accurate SEFA preparation. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has implemented new process to ensure accurate preparation of their SEFA’s.
We will reconcile the reports submitted to the federal awarding agency to the expenditures recorded in the accounting records and SEFA to ensure accurate reports going forward.
We will reconcile the reports submitted to the federal awarding agency to the expenditures recorded in the accounting records and SEFA to ensure accurate reports going forward.
We will implement the required procedures surrounding the subrecipient monitoring process and follow them consistently.
We will implement the required procedures surrounding the subrecipient monitoring process and follow them consistently.
We plan to start the next fiscal year's audit right after issuance of September 30, 2023 financial statements to catch up on the filing of the reporting package.
We plan to start the next fiscal year's audit right after issuance of September 30, 2023 financial statements to catch up on the filing of the reporting package.
Root Cause Management concurs that federal expenditures totaling approximately $5,842,346 under ALN 21.029 were omitted from the initially prepared SEFA, along with an additional $206,139 of other federal programs, for a total of $6,048,485. The omission resulted from incomplete grant tracking repor...
Root Cause Management concurs that federal expenditures totaling approximately $5,842,346 under ALN 21.029 were omitted from the initially prepared SEFA, along with an additional $206,139 of other federal programs, for a total of $6,048,485. The omission resulted from incomplete grant tracking reports not reconciled to the general ledger and grant agreements; absence of an independent secondary review; and procedures that did not fully capture pass-through and subrecipient activity. Objective Design and implement effective internal controls to ensure the SEFA is complete, accurate, and in compliance with 2 CFR §200.510(b) and §200.303; prevent recurrence of material omissions; and sustain readiness for Single Audit reporting. 1. Comprehensive Reconciliation Process Implement a standardized monthly and year-end reconciliation that ties federal award expenditures (including drawdowns and indirect costs) to the general ledger, award agreements/portals, and program manager reports. Create a SEFA Reconciliation Workbook with crosswalks by ALN, passthrough entity, award number, program, and period of performance. 2. Federal Awards Inventory & Certification Maintain a centralized Federal Awards Inventory listing all awards by ALN, award number, passthrough entity, and funding stream. Require annual certifications from responsible leadership team members confirming completeness and accuracy of reported expenditures and period-of-performance coverage. 3. Formal Review Workflow (Independent of Preparer) Establish a documented two-tier review: (1) VP of Finance prepares SEFA and reconciliation; (2) Leadership Team Members perform independent reviews using a SEFA Checklist covering ALNs, pass-throughs, subrecipient disclosures, notes (basis, indirect cost rate), and period-of-performance matching. Evidence the review via dated sign-offs. 4. Subrecipient & Pass-through Controls The VP of Finance create procedures to identify all pass-through and subrecipient transactions. Maintain subrecipient listings with amounts passed through and ensure required disclosures (ALN, pass-through numbers) are captured in SEFA. Reconcile subrecipient agreements and payment registers to SEFA. Leadership Team Members perform independent reviews for accuracy and completeness. 5. Close Calendar & Training Adopt an annual SEFA close calendar with milestones (pre-close, interim, final). Provide annual training for finance and program staff on Uniform Guidance reporting requirements and the SEFA Checklist; include updates to OMB Compliance Supplement as applicable. 6. Monitoring & Continuous Improvement Quarterly CAP monitoring by VP of Finance with status reports to the Finance Committee. Track metrics (e.g., % variance between GL and SEFA, number of checklist exceptions) and remediate promptly. Conduct a pre-audit SEFA "dry run" at least 60 days before year-end close. Roles & Responsibilities • VP of Finance: CAP owner; oversight, quarterly monitoring, reports to Finance Committee, designs reconciliation and review workflow; ensures adherence to checklist and certifications; prepares SEFA, reconciliation workbook, and supporting schedules. • Responsible Leadership Team Member/Program Managers: Certify award activity and completeness; provide supporting documentation. Timeline & Milestones Immediate (within 30 days): Approve CAP; establish Federal Awards Inventory template; draft SEFA Checklist; schedule training. Short term (within 60-90 days): Implement monthly reconciliation; obtain program certifications; pilot independent review on QI data. By next year-end close: Execute full close calendar; complete pre-audit SEFA dry run; document reviewer sign-offs; present monitoring results to Finance Committee. Compliance References • 2 CFR §200.510(h): SEFA preparation requirements (completeness, ALN, pass-through, etc.). • 2 CFR §200.303: Internal controls over federal awards. Management Statement (for 2 CFR §200.511(c) submission) Management agrees with the finding and has initiated the corrective actions described herein. The CAP will be monitored quarterly by the VP of Finance, with status updates provided to those charged with governance until all actions are fully implemented and operating effectively.
Corrective Action Plan Action Item Responsible Party Timeline Monitoring Establish procedures to track and monitor all federal reporting deadlines, including SF-425 and UDS reports. CFO Immediate Monthly review Maintain supporting documentation for federal financial and program reports in accordance...
Corrective Action Plan Action Item Responsible Party Timeline Monitoring Establish procedures to track and monitor all federal reporting deadlines, including SF-425 and UDS reports. CFO Immediate Monthly review Maintain supporting documentation for federal financial and program reports in accordance with record-retention policies. CFO / Accounting Staff Immediate Periodic internal review Implement supervisory review procedures to verify the accuracy and timeliness of federal reports prior to submission. CFO / Executive Management Immediate Each reporting cycle Establish formal turnover procedures for federal reporting responsibilities to ensure continuity of reporting and documentation during personnel transitions. CFO Within 30 days Management oversight ________________________________________ Management Response Management, under the direction of the Chief Financial Officer, acknowledges the findings related to the timeliness of federal financial reporting. Management recognizes that the late submission of certain SF-425 reports resulted from prior turnover in accounting and executive management personnel and the absence of formal procedures for monitoring federal reporting deadlines and maintaining supporting documentation. As of FY2026, management implemented supervisory oversight and a personnel exit clearance process to ensure continuity and completeness of financial records. Management also provides the Board with updates on personnel transitions and associated risks to support proper oversight and timely remediation of identified issues. As of FY2026, procedures have been implemented requiring that all supporting documentation and attachments be uploaded and maintained within the online accounting system and google shared drive to strengthen internal controls, improve transparency, and ensure consistent documentation practices.
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