Corrective Action Plans

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Finding 390452 (2023-003)
Significant Deficiency 2023
Corrective Actions Taken or Planned: Going forward for payments, under the direction of the Executive Director, Rachel Erpelding, the Kim Wilson Housing Staff will sign-off on the access database check request sheets and have the Executive Director provide her physical signature as written evidence ...
Corrective Actions Taken or Planned: Going forward for payments, under the direction of the Executive Director, Rachel Erpelding, the Kim Wilson Housing Staff will sign-off on the access database check request sheets and have the Executive Director provide her physical signature as written evidence of the review and approval process for housing payments. For drawdowns, beginning July 2023, the Director of Fiscal Services, Linnea Cullumber, implemented a monthly reconcile process between the housing check payment requests and grant billing drawdown support provided by the Kim Wilson Housing Staff. The accounting staff now reconcile the payment and drawdown support, then retain the email correspondence supporting the drawdown process providing confirmation of review and approval. Rachel Erpelding, Executive Director of Kim Wilson Housing, and Linnea Cullumber, Director of Fiscal Services are responsible for this corrective action plan. The anticipated completion date is 3/31/24.
Finding 390451 (2023-002)
Significant Deficiency 2023
Corrective Actions Taken or Planned: Under the direction of the Executive Director, Rachel Erpelding, the Grant Specialist with Kim Wilson Housing is responsible for collecting data and tracking the grant match total in the housing access database. During the fiscal year ended June 30, 2023, there ...
Corrective Actions Taken or Planned: Under the direction of the Executive Director, Rachel Erpelding, the Grant Specialist with Kim Wilson Housing is responsible for collecting data and tracking the grant match total in the housing access database. During the fiscal year ended June 30, 2023, there wasn’t a 2nd level physical signature of approval on the match tracking documents. Going forward, the Grant Specialist will print and sign the match tracking document and the Executive Director will approve the printed tracking sheet from the housing database. Rachel Erpelding, Executive Director of Kim Wilson Housing, is responsible for this corrective action plan. The anticipated completion date is 3/31/24.
2023-008 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F – Cash Management Recommendation: We recommend the University formally document, establish controls and monito...
2023-008 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F – Cash Management Recommendation: We recommend the University formally document, establish controls and monitor advances in federal funds to ensure time elapsing between the transfer of funds and disbursement is minimized and any interest required to be remitted is calculated and returned on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will formally document, establish controls and monitor advances in federal funds to ensure time elapsing between the transfer of funds and disbursement is minimized and any interest required to be remitted is calculated and returned on a timely basis. Name(s) of the contact person(s) responsible for corrective action: Assistant Controller, Clifton Smith, II Planned completion date for corrective action plan: June 2024
View Audit 301226 Questioned Costs: $1
The City Controller, City Engineer and Director of Community and Economic Development have held recent meetings to discuss the development of a SharePoint site for all grant documentation. Thus far, there has not been a centralized location for award documents that can be accessed by all necessary p...
The City Controller, City Engineer and Director of Community and Economic Development have held recent meetings to discuss the development of a SharePoint site for all grant documentation. Thus far, there has not been a centralized location for award documents that can be accessed by all necessary parties. A draft SEFA worksheet will be created and updated on an ongoing basis throughout the fiscal year. This will improve the accuracy of internal federal award data. Louise Biron will be responsible for this finding and the anticipated completion date is June 30, 2024.
REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radi...
REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan origination and disbursement records to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Corrective Action Plan: This finding has been corrected for Good Samaritan. In May 2023, for April 2023 data, Good Samaritan implemented a formal monthly reconciliation process, including comparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting any explaining any differences, proper sign off for preparation and review and the date by Good Samaritan management for presentation to the Compliance Oversight Committee. A year end reconciliation is also performed following the same process. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science and Financial Aid Services (FAS) David Velasquez, Nuclear Medicine Technologist Coordinator (CHI Health School of Radiologic Technology) Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)
REFERENCE: 2023-005 – Cash Management Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samar...
REFERENCE: 2023-005 – Cash Management Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Corrective Action Plan: This finding has been corrected for Good Samaritan. In May of 2023, for April 2023 data, Good Samaritan implemented a formal monthly reconciliation process, including comparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting any explaining any differences, proper sign off for preparation and review and the date by Good Samaritan management and FAS management. This review is presented monthly to the Compliance Oversight Committee. A year end reconciliation is also performed following the same process. CHI Health School of Radiologic Technology will implement a review control for accounting staff to review the draw down amount provided by the School prior to completing the drawn down. Documentation of the review will be retained. Person Responsible: Judy Kronenberger, President, Good Samaritan College of Nursing and Health Science and Andrea Heffelfinger, Market Director of Accounting (CHI Health) Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)
Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C2...
Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C210057 and P031C210077, October 1, 2021 through September 30, 2026 P031S220015 and P031S220179, October 1, 2022 through September 30, 2027 Federal Agency: U.S. Department of Education Compliance Requirements: Reporting and special tests and provisions Questioned costs: Unknown Name of contact persons: Kristina Winterstein, Associate Controller, District Business Services Diana Aguirre-Rosales, Fiscal Director, Maricopa Community Colleges Foundation Anticipated completion date: December 31, 2024 The District is aware of the importance of ensuring that reports submitted are reviewed for accuracy prior to submission and implemented new processes for report review and submission in November 2023. On February 7, 2024, after multiple requests, the U.S. Department of Education (ED) provided the District with access to ED’s reporting system, which will allow the District to timely submit reports. The District will coordinate with the Maricopa Community Colleges Foundation to ensure that the endowment contracts include all necessary federal regulation information and that the investment and disbursement of funds are in accordance with federal regulations.
View Audit 301142 Questioned Costs: $1
KVC Hospitals, Inc. - Effective Internal Controls related to the Financial Statements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The Organization is going to continue and improve its understanding of the guidance related to this type of reporting and ...
KVC Hospitals, Inc. - Effective Internal Controls related to the Financial Statements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The Organization is going to continue and improve its understanding of the guidance related to this type of reporting and work with their external advisors to ensure future portal submissions are compliant with said guidance. Going forward, the Organization will continue to improve its internal controls related to lost revenue calculations and reporting and work with their external advisors to ensure future portal submissions, if any, are compliant with said guidance. The under-reporting of lost revenues had no impact on the Organization’s ability to cover the total Provider Relief Fund payments received. This review will be performed by June 30, 2024. Responsible Official: Sherri Lohe Chief Financial Officer
Finding 390226 (2023-002)
Significant Deficiency 2023
We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices ...
We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices of recording and maintaining records. We have since also consolidated our supply chain so that spenders are able to procure most supplies through one vendor, which will have reporting and tracking capabilities. We will also be making significant changes to how mileage reimbursement is documented and approved.
Finding # 2023-001 Material weakness over allowable costs U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Only allowable costs may be charged to the contract for reimbursement. One out of six invoices charged to the contract was an unallowable expense (sc...
Finding # 2023-001 Material weakness over allowable costs U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Only allowable costs may be charged to the contract for reimbursement. One out of six invoices charged to the contract was an unallowable expense (scholarships). Recommendation: Expenses charged to contract should be reviewed thoroughly and be in compliance with contract agreement. Management should have understanding of what costs are considered allowable and unallowable. Corrective Action: We will have the Executive Director, Business Manager and College+ Program Manager thoroughly review the monthly Talent Search billing before completing a drawdown to ensure that all expenses billed are allowable costs. Anticipated Completion Date: June 30, 2024
Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calenda...
Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calendar developed by ALASBO which addresses all reporting requirements for the school districts in Alaska. Proposed Completion Date: March 31, 2024
Finding 390159 (2023-003)
Significant Deficiency 2023
Finding Reference Number: SA2023-003 Cash Management - Draw Down of Community Development Block Grant Funds in Advance of Disbursement Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Bloc...
Finding Reference Number: SA2023-003 Cash Management - Draw Down of Community Development Block Grant Funds in Advance of Disbursement Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0010 COVID-19 - B-20-MW-06-0010 • Fiscal Year of Initial Finding: 2023 • Name(s) of the contact person: Traci Cho, Accountant • Corrective Action Plan: The City will review the retentions payable when preparing the IDIS drawdown to ensure that retentions are not included in the drawdown amount. • Anticipated Completion Date: 06/30/24
View Audit 301060 Questioned Costs: $1
Management Response: The BOCES will assure internal control procedures are in place to verify that all grant funding requests meet Cash Management requirements. Reimbursements will be requested subsequent to the expenditure of grant funds. The BOCES will establish internal controls whereby the gran...
Management Response: The BOCES will assure internal control procedures are in place to verify that all grant funding requests meet Cash Management requirements. Reimbursements will be requested subsequent to the expenditure of grant funds. The BOCES will establish internal controls whereby the grant manager determines the amount to be requested and this will be subsequently verified by finance staff to ensure that total requests do not exceed incurred or obligated expenditures. A review of the internal control procedures with all grant management and finance staff will assure that this is not a reoccurring issue.
Individual Responsible for Corrective Action: Don Barton, Controller Corrective Action: Cash management of Title IV funds at the University is generally performed only on a reimbursement basis. In this situation there was a one-time error in calculating available FWS funds and year-to-date FWS ear...
Individual Responsible for Corrective Action: Don Barton, Controller Corrective Action: Cash management of Title IV funds at the University is generally performed only on a reimbursement basis. In this situation there was a one-time error in calculating available FWS funds and year-to-date FWS earnings such that approximately $11,000 in excess cash was received near the end of the 21-22 year and then carried forward. The error was discovered early in 22-23 but by that point earnings had outpaced cash on hand and so no effort was made to return funds. A new procedure with a multi-year workbook has been established for monitoring FWS earnings across award periods to prevent a repeat occurrence. Anticipated Completion Date: August 15, 2024
As mentioned previously, there was a staffing change with a grant billed which helped make YSS aware of an internal control breakdown in the billing process. Along with the issue where revenue was posted but invoices were not sent, it was also found that many workpapers that should have been in pla...
As mentioned previously, there was a staffing change with a grant billed which helped make YSS aware of an internal control breakdown in the billing process. Along with the issue where revenue was posted but invoices were not sent, it was also found that many workpapers that should have been in place to support the invoices were disorganized, lacked an audit trail, or in some cases did exist aside from a handful of brief notes, especially in cases where grants were drawn in 1/12th increments. While many worksheets were created or greatly enhanced already, the grant billers are currently engaging in a new process to begin cost tracking for the grants which have allowed 1/12th without consistently asking for such supporting workpapers.
Special Tests and Provisions: In accordance with the Project's regulatory agreement with HUD, management shall establish a residual receipts account and make deposits into the account in accordance with HUD requirements (within 90 days after the close of the fiscal year). Disbursements from such fun...
Special Tests and Provisions: In accordance with the Project's regulatory agreement with HUD, management shall establish a residual receipts account and make deposits into the account in accordance with HUD requirements (within 90 days after the close of the fiscal year). Disbursements from such fund may be made only after written consent is received from HUD, Management's View: Management acknowledges finding and simultaneously underscores this was an internal facing situation. Proposed Corrective Action: Management will ensure that all proper approvals from HUD are obtained before making a withdrawals from residual receipts account. Anticipated Correction Date: Correction has been implemented.
We agree with this finding and have taken steps to prevent this from occurring in the future. Our policy has been to make surplus cash deposits after the final audit has been issued. A residual receipts account has been established and the required fiscal year 2022 surplus cash deposit of $17,660 ha...
We agree with this finding and have taken steps to prevent this from occurring in the future. Our policy has been to make surplus cash deposits after the final audit has been issued. A residual receipts account has been established and the required fiscal year 2022 surplus cash deposit of $17,660 has been made to the account on October 21, 2022.
Finding Number: 2023‐001 Program Names/Assistance Listing Titles: Indian School Equalization, Administrative Cost Grants for Indian Schools, Indian Education Facilities, Operations and Maintenance Assistance Listing Numbers: 15.042, 15.046, 15.047 Contact Person: Stephanie Woody, Business Technician...
Finding Number: 2023‐001 Program Names/Assistance Listing Titles: Indian School Equalization, Administrative Cost Grants for Indian Schools, Indian Education Facilities, Operations and Maintenance Assistance Listing Numbers: 15.042, 15.046, 15.047 Contact Person: Stephanie Woody, Business Technician; Aurelia Tapaha, Business Manager/Human Resource Manager; Jeannie Lewis, Principal Anticipated Completion Date: July 2024 Planned Corrective Action: The School will review the procurement flowcharts and required documents for Business Technician. The School will obtain training for chart of accounts training for business staff along with procurement training. Business staff and administrators will keep abreast of law changes, GASB updates, and budget changes with grants received. The School will review school credit and implement a timeframe where the no use of the credit card is enforced. The School will collect all required documents to process payments. The entire balance will be paid in full amount for each month. Training on use of credit cards will be given during orientation.
Finding_ 2023-001 Recommendation: The college should establish procedures to ensure proper review and compliance with disbursements of federal funds, including controls over compliance, to ensure that federal funds are disbursed to student accounts in a timely manner in accordance with federal regul...
Finding_ 2023-001 Recommendation: The college should establish procedures to ensure proper review and compliance with disbursements of federal funds, including controls over compliance, to ensure that federal funds are disbursed to student accounts in a timely manner in accordance with federal regulations and conditions. Corrective Action: A control has been added to reconcile the posting of student federal monies with federal funds received by the college. The VP of Finance and Administration with coordinate with the Financial Aid officer to ensure funds are properly posted in a timely and compliant manner. Person Responsible for Corrective Action: Michael Molla, President Anticipated Completion Date for Corrective Action: The Corrective Action will be immediately implemented in response to the auditor's recommendation.
View Audit 300776 Questioned Costs: $1
Finding number: 2023-002 Federal agency: U.S. Department of Education Programs: Higher Education Emergency Relief Fund Assistance Listing #: 84.425F, 84.425L Award year: 2023 Corrective Action Plan: We agree with this audit finding. As stated in our response to the prior year audit’s find...
Finding number: 2023-002 Federal agency: U.S. Department of Education Programs: Higher Education Emergency Relief Fund Assistance Listing #: 84.425F, 84.425L Award year: 2023 Corrective Action Plan: We agree with this audit finding. As stated in our response to the prior year audit’s finding, we did not realize that under the HEERF III Issued Guidelines/(FAQs) that as a grantee we were under an obligation to minimize the time between drawing down funds from G5 and paying obligations incurred by the college/grantee. We had thought that the related guidelines were similar to CARES/HEERF I and we wanted to ensure that we had drawn down the funds timely once they were awarded to the college. We have since coordinated with the Office of Postsecondary Education, United States Department of Education to reimburse them for interest income earned on unspent funds and returned the remaining/unused funds for the HEERF III Institutional Aid portion and the Minority Serving Institutional Funds portion. The College spent $41,007 of the remaining HEERF III Institutional Aid funds during the 90-day HEERF liquidation period after discussion with the United States Department of Education and returned the remaining amount of $70,031 in February 2024. The College returned the HEERF III Minority Serving Institutional Funds remaining amount of $144,014 in February 2024. The interest the College earned and returned to the United States Department of Education on the unspent funds amounted to $125,324, which was paid in two installments in July 2023 and February 2024. Timeline for Implementation of Corrective Action Plan: The corrective action plan has been implemented as of January 8, 2024. Contact Person Anthony DeGregorio, Comptroller & Director of Fiscal Services
View Audit 300758 Questioned Costs: $1
The Accounting Manager will educate the Senior Management Team so that all departments are aware of this finding and the steps to prevent its recurrence. The Accounting Manager will work in conjunction with the Grant/Staff Accountant and/or Senior Accountant to ensure that monthly Meals on Wheels sp...
The Accounting Manager will educate the Senior Management Team so that all departments are aware of this finding and the steps to prevent its recurrence. The Accounting Manager will work in conjunction with the Grant/Staff Accountant and/or Senior Accountant to ensure that monthly Meals on Wheels spreadsheet totals reconcile with the meals within the Serv Tracker reporting. Procedures will be revised as necessary and documented. Staff will be trained on new procedure. Responsible Party: Judy Arellano Accounting Manager 603-352-2253 Anticipated Completion Date: 4/15/24
Name of Responsible Individual: Mary Beth Schiller-Schwenke, Controller Corrective Action: The FWS Program instances were the result of a minor type error on the federaldraw reconciliation worksheet. To prevent a similar error in the future, the Business Office has modified its draw recordkeeping pr...
Name of Responsible Individual: Mary Beth Schiller-Schwenke, Controller Corrective Action: The FWS Program instances were the result of a minor type error on the federaldraw reconciliation worksheet. To prevent a similar error in the future, the Business Office has modified its draw recordkeeping process to require the employees that record or approve the draw journal entry also review the draw worksheet for accuracy and correct if needed. The FSEOG Program instances resulted from reversals of student awards in fiscal year 2024 for the fiscal year 2023. The Business Office routinely monitors the general ledger for award transactions, however, reversals of student aid awarded in a prior fiscal year can be offset by current year activity and missed. The Financial Aid Office will be responsible to notify the Business Office when they initiate prior award transactions. In addition to the weekly monitoring of the related general ledger accounts, the Business Office will also generate financial aid award reporting and monitor for changes. Anticipated Completion Date: February 28, 2024
Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are stan...
Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are standard practice in our organization were not being completed. In addition, the filing of certain documentation to support expenditures was not being done consistently. The Director of Finance position was not filled until November 2022. As a result, documentation of allowable expenditures is being addressed for the fiscal 2023 audit. In addition to turnover, the organization transitioned to a new general ledger system with a new chart of accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certain data pertaining to the federal programs was not being captured. Management has informed all staff of the requirements to track federal programs within the general ledger accounts. Anticipated Completion Date: September 30, 2024 Responsible Contact Person: Erica Tkachyk, Director of Finance
View Audit 300711 Questioned Costs: $1
Views of responsible officials and planned corrective action: The Authority acknowledges that this error occurred. When we identified this issue, we contacted the grantor agency for guidance. They explained how to submit a refund and acknowledged that since the grant was still open, we had the ab...
Views of responsible officials and planned corrective action: The Authority acknowledges that this error occurred. When we identified this issue, we contacted the grantor agency for guidance. They explained how to submit a refund and acknowledged that since the grant was still open, we had the ability to correct an incorrect draw. This refund has been processed and the Authority has put additional internal controls in place to ensure the proper match is calculated for each grant draw in the future. Additionally, upon final grant closeout, all the numbers are verified and reconciled back to the grant agreement, including the match.
AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Jackson Public School District has prepared and hereby submits the following corrective a...
AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Jackson Public School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Cost for the year ended June 30, 2023: Finding 2023-001 Corrective Action Plan Details A.    Contact person responsible for corrective action: Name: Marc Rowe Title: Executive Director B.    Description of corrective action planned: The district will implement and strengthen its internal control systems over reporting and submitting its monthly claims for reimbursement to ensure claims are submitted within established reporting deadlines. C.    Anticipated completion date of corrective action: 6/30/2024
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