Corrective Action Plans

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Finding Number: 2023-005 Finding Title: Reporting (DHS 2550 and 2556) Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services fiscal staff will review the new detailed instructions...
Finding Number: 2023-005 Finding Title: Reporting (DHS 2550 and 2556) Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services fiscal staff will review the new detailed instructions on how to complete the referenced quarterly reports that include recent changes. Staff will correct an resubmit quarterly reports as requested. Anticipated Completion Date: January 20, 2025
Finding Number: 2023-004 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services Fiscal departmen...
Finding Number: 2023-004 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services Fiscal department will work on identifying allowable and unallowable expenditures that are submitted on these reports, so only allowable expenditures are submitted going forward. Anticipated Completion Date: Completed, September 7, 2024
Finding 498508 (2023-003)
Significant Deficiency 2023
Finding Number: 2023-003 Finding Title: Procurement Policy Program: 20.205 Highway Planning and Construction Name of Contact Person Responsible for Corrective Action: Kit Johnson, County Auditor/Treasurer Corrective Action Planned: Traverse County has updated their procurement policy to comply with ...
Finding Number: 2023-003 Finding Title: Procurement Policy Program: 20.205 Highway Planning and Construction Name of Contact Person Responsible for Corrective Action: Kit Johnson, County Auditor/Treasurer Corrective Action Planned: Traverse County has updated their procurement policy to comply with the latest changes in the law. Anticipated Completion Date: Completed, May 21, 2024
Finding no.: 2023-001 Contact person(s) responsible: Sally Alworth Corrective action planned: As of April 15, 2023, a new timecard system was implemented and charges to grants are supported by actual timecard entries. Timecards are approved by the employee and reviewed by a supervisor prior to...
Finding no.: 2023-001 Contact person(s) responsible: Sally Alworth Corrective action planned: As of April 15, 2023, a new timecard system was implemented and charges to grants are supported by actual timecard entries. Timecards are approved by the employee and reviewed by a supervisor prior to payroll processing. Anticipated completion date: April 15, 2023
Identifying Number: 2023-003 Finding: Timely Submission of the Data Collection Form Corrective Actions Taken or Planned: Management’s Response to Audit Finding on Timely Submission of the Data Collection Form During the 2023 calendar year, AACAP (The Academy) did not submit the 2022 data collect...
Identifying Number: 2023-003 Finding: Timely Submission of the Data Collection Form Corrective Actions Taken or Planned: Management’s Response to Audit Finding on Timely Submission of the Data Collection Form During the 2023 calendar year, AACAP (The Academy) did not submit the 2022 data collection form within nine months after the end of the audit period. Management takes this deficiency seriously and is committed to improving the timeliness of accounting functions. The following procedures are being implemented: 1. An outsourced accounting and consulting firm provided 2023 financial services to the Academy and worked in conjunction with a federal grant consultant bring federal reports current. Additionally, the Academy hired in-house financial staff with experience in federal grant reporting to oversee the process. We expect that 2023 and future federal reports will be filed on a timely basis. Name of Responsible Person: Heidi Fordi, Executive Director/CEO Projected Date of Completion: September 23, 2024
Name(s) of the contact person(s) responsible for corrective action: Richard Marshall Planned completion date for corrective action plan: 12/31/2025 2023-002 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 – Rent Reasonableness Recommendation: We recommend management to implement contr...
Name(s) of the contact person(s) responsible for corrective action: Richard Marshall Planned completion date for corrective action plan: 12/31/2025 2023-002 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 – Rent Reasonableness Recommendation: We recommend management to implement controls over the recertification and rent change process to ensure determination of reasonable rent is performed prior to processing of the move in. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Continue to perform quality control on files and note any pattern that develops for the same type of errors and take corrective action if a pattern develops. Name(s) of the contact person(s) responsible for corrective action: Richard Marshall Planned completion date for corrective action plan: 12/31/2025
Housing Voucher Cluster – Assistance Listing No. 14.871 / 14.879 – Eligibility Recommendation: We recommend management to implement controls and policies to ensure compliance with eligibility requirements. Additional training for housing specialists would also improve accuracy. Explanation of disagr...
Housing Voucher Cluster – Assistance Listing No. 14.871 / 14.879 – Eligibility Recommendation: We recommend management to implement controls and policies to ensure compliance with eligibility requirements. Additional training for housing specialists would also improve accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Monitor and quality control documents as required by HUD. If quality control determines there is a pattern of the same type of discrepancy, then corrective actions will be taken. The finding is based on 2 late reexaminations and failure to automatically identify a client as disabled. This is marked as a repeat finding in the same category, but is not the same type of finding as last year.
Finding 498472 (2023-002)
Significant Deficiency 2023
The City will review the wage-rate testing prepared by the consultant and formally document their review
The City will review the wage-rate testing prepared by the consultant and formally document their review
Finding 498471 (2023-001)
Significant Deficiency 2023
The City will review the reports prepared by the consultant and formally document their review
The City will review the reports prepared by the consultant and formally document their review
Management’s response and corrective action is as follows: Architect certification is not required by the Department of Housing and Urban Development nor our policies and procedures. It is listed in our contracts as one of the many different types of reimbursement documentation our office will acc...
Management’s response and corrective action is as follows: Architect certification is not required by the Department of Housing and Urban Development nor our policies and procedures. It is listed in our contracts as one of the many different types of reimbursement documentation our office will accept. For many projects, an architect certification for each draw would be financially prohibitive and would likely reduce the financial viability of affordable housing developments. Our office does conduct intermittent on-site or desktop monitoring throughout the course of the project to ensure evidence activities. Additionally, all construction projects must complete permit requirements to ensure housing quality. Evidence of monitoring or activity was provided to the auditors. Expected Implementation Date: October 2024 Contact person: Marlee Pittman Miller, Director, Mayor-President’s Office of Community Development
Management’s response and corrective action is as follows: After reviewing the condition, cause, and effect of the presented Finding, the City-Parish finds it important to clarify that the duplicative charges were initially identified and documented as a self-reported finding. This discrepancy was...
Management’s response and corrective action is as follows: After reviewing the condition, cause, and effect of the presented Finding, the City-Parish finds it important to clarify that the duplicative charges were initially identified and documented as a self-reported finding. This discrepancy was discovered during the subrecipient monitoring component of this award and was promptly reported and reconciled prior to being presented as an audit finding. Upon identification of the duplicative charges, totaling approximately $22,000, immediate corrective action was taken to address the non-compliance. Dated January 5, 2024, a memorandum was filed disclosing the duplicative reimbursements, documenting the actions taken to rectify these charges, and recommending further steps to enhance the internal controls of the non-profit organization. The following information summarizes the East Baton Rouge City-Parish American Rescue Plan Act (ARPA): Duplication of Benefits - Findings and Corrective Action Memorandum: This memorandum documents the incidental reimbursement of multiple duplicative items associated with the subrecipient’s grant agreement and the corrective actions undertaken to resolve these findings, ensuring compliance with the terms of this award. During the routine subrecipient monitoring reviews, it was discovered that duplicate reimbursements occurred for 12 items between separate federal awards (American Rescue Plan Act SLFRF and CARES Act). In accordance with 2 CFR 200.522(c), a corrective action plan was provided to resolve the non-compliance. To address this, the following actions were taken: 1) Reconciliation of Duplicate Reimbursements: The non-profit entity has since reconciled the total value of $22,222.98 in duplicate reimbursements with an equivalent value of eligible expenses, including all necessary backup documentation to satisfy existing procurement and reimbursement requirements. 2) Development of a Duplication of Benefits Policy: It was recommended that the non-profit entity develop a comprehensive duplication of benefits policy to strengthen their internal controls further. These additional safeguards are considered best practices and are intended to minimize the risk of future non-compliance. Additionally, a comprehensive, grant specific, financial management policy template was provided to support the non-profits action to adopt and implement an appropriate standard of internal controls. The City-Parish is committed to maintaining robust internal controls and ensuring compliance with federal regulations. Immediate corrective measures were proactively taken to address these duplicative charges. Additionally, the City-Parish's third-party grants manager has established recurring weekly monitoring meetings with the non-profit entity to support the development and implementation of an adequate system of internal controls. Continuous efforts are being made to improve these processes to prevent such issues in the future. Expected Implementation Date: January 2024 Contact person: Courtney Scott, Assistant Chief Administrative Officer, Mayor-President’s Office
View Audit 321162 Questioned Costs: $1
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) Audit Finding Number: 2023-004 – Medicaid and CHIP Receipt Controls Name of the contact person responsible for corrective acti...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) Audit Finding Number: 2023-004 – Medicaid and CHIP Receipt Controls Name of the contact person responsible for corrective action: Ashley Logan Anticipated completion date for corrective action: June 30, 2024 Recommendation: The DSS through the MHD review, strengthen, and enforce internal controls over Medicaid and CHIP receipts. The MHD should restrict user access within the MMIS for FORU accounting personnel and adequately segregate asset custody and receipt recording duties from accounts receivable duties, or perform documented supervisory reviews of MMIS entries and changes made by employees whose duties are not segregated. In addition, the MHD should establish procedures to account for all cash control numbers to ensure all receipts are deposited or returned to senders. DSS Response: DSS agrees with the auditor's finding. Our Corrective Action Plan includes the department’s planned actions to address the finding. Corrective action planned is as follows: MHD has implemented a process to document supervisory reviews of the Finance Manual Checks Quarterly report to ensure segregation of duties in HeathTrack/AHS. MHD will continue to perform the audit of clerk ID adhoc reports to review any segregation of duties within the MMIS. To ensure all cash control numbers are accounted for, MHD is implementing a new cash control number sequence, exclusive to manual checks logged within the FORU. This will resolve the issue of cash control numbers occurring out of sequence due to AHS running files in the background at the same time checks are being logged.
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) Audit Finding Number: 2023-002 - Medicaid Management Information System Access Name of the contact person responsible for cor...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) Audit Finding Number: 2023-002 - Medicaid Management Information System Access Name of the contact person responsible for corrective action: Christopher Boyle Anticipated completion date for corrective action: March 10, 2024 Recommendation: The DSS through the MHD review user access to the MMIS annually and ensure inappropriate access, including that of terminated users, is removed in a timely manner. DSS Response: DSS agrees with the auditor’s recommendation. The Corrective Action Plan includes the department’s planned actions to address the finding. Corrective action planned is as follows: MHD will continue to perform the annual review, but to ensure that the annual review is completed timely, monthly calendar meetings have been created. The FY24 annual review is in progress. In addition to the annual review, instead of relying on supervisors to inform MHD of terminations, MHD staff have updated the off-boarding process to identify additional eMOMED and eMMIS users who no longer require access. MHD staff are comparing the MMIS active user lists with lists of terminated users. When an active user is located on a termination list, a request to disable the MMIS account is submitted.
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) Audit Finding Number: 2023-001 - Medicaid National Correct Coding Initiative Name of the contact person responsible for corre...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) Audit Finding Number: 2023-001 - Medicaid National Correct Coding Initiative Name of the contact person responsible for corrective action: Kim Johnson Anticipated completion date for corrective action: July 1, 2024 Recommendation: The DSS through the MHD continue to strengthen controls over the NCCI requirements to ensure claims are reprocessed when NCCI edits are not implemented timely, as required. DSS Response: DSS agrees with the auditor’s recommendation. The Corrective Action Plan includes the department’s planned actions to address the finding. Corrective action planned is as follows: The DSS through the MHD will continue to update the NCCI edits quarterly, within the Centers for Medicare & Medicaid Services (CMS) requirement that the files must be implemented by the beginning of the second month of the calendar quarter. MHD will reprocess January 1, 2023, through February 17, 2023. MHD is not reprocessing claims submitted July 1, 2022, through August 22, 2022, as the system changes were not in place until August 23, 2022. Any claims for this time frame submitted after August 22, 2022, were subject to the updated NCCI edits. Moving forward, claims will be reprocessed when changes are not in the system, as required by CMS.
Finding 498419 (2023-017)
Significant Deficiency 2023
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2023-017 DESE FFATA Reporting Name of the contact person responsible for corrective action: Shelley Woods Anticip...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2023-017 DESE FFATA Reporting Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion date for corrective action: July 1, 2024 Corrective action planned is as follows: DESE expended over $2.5 billion in federal funds in FY23, of which approximately $1.8 billion was applicable to FFATA reporting. While this CCDF grant finding constitutes less than 1% of an error rate in FFATA reporting, DESE agrees with the auditor's conclusion and will strengthen internal controls surrounding FFATA reporting. The grant has been reported in FSRS as of November 2023 to meet FFATA requirements. While procedures were updated in FY24 to strengthen internal controls based on previous findings, DESE has made further revisions to the procedure and grant tracking forms to ensure FFATA compliance.
023-005 –ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third-party management c...
023-005 –ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third-party management company to ensure compliance with 24 CFP 960.259 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
Finding 2023-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions – Housing Quality Standards (HQS) Enforcement Non Complianc...
Finding 2023-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions – Housing Quality Standards (HQS) Enforcement Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: HQS Enforcement. For units under HAP contract that fail to meet HQS, the PHA must require the owner to correct all life threatening HQS deficiencies within 24 hours after the inspections and all other deficiencies within 30 days or within a specified PHA-approved extension. Condition: Based upon inspection of the Authority’s files and on discussion with management, the Authority did not properly abate one (1) out of twenty-five (25) annual failed inspections selected for testing. Context: The Authority did not properly abate one (1) out of twenty-five (25) failed inspections selected for testing. As a result, the Authority was not in compliance with the HQS as required by 24 CFR sections 982.158(d) and 982.405(b). Known Questioned Costs: $1,532 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS enforcement. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS enforcement. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Philisa Smith, HCV Director, is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring by December 31, 2024.
View Audit 321110 Questioned Costs: $1
Finding 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program, Federal Catalog Numbers: 14.871 Noncompliance - E - Eligibility Non Compliance Material to the Financial Statements: No Significant Deficiency in Inte...
Finding 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program, Federal Catalog Numbers: 14.871 Noncompliance - E - Eligibility Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of forty-three (43) tenant files, the following information was unavailable for examination at the time of audit: (3) Verification of Income (2) Verification of Assets HUD Form 50058 Our sample size is statistically valid. Known Questioned Costs: 7,162 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Section 8 Housing Choice Voucher Program is in non-compliance with the eligibility type of compliance requirements of the program. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Philisa Smith, HCV Director, is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring by December 31, 2024.
View Audit 321110 Questioned Costs: $1
Management is cognizant of this limitation and will implement additional procedures where possible.
Management is cognizant of this limitation and will implement additional procedures where possible.
Finding 498367 (2023-003)
Significant Deficiency 2023
Upon start of employment of a new City Administrator/Treasurer on October 9, 2023, that employee will be reviewing such reports and financial documents on a regular basis as part of his job duties.
Upon start of employment of a new City Administrator/Treasurer on October 9, 2023, that employee will be reviewing such reports and financial documents on a regular basis as part of his job duties.
2019-01: Segregation of Duties Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to com...
2019-01: Segregation of Duties Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregating certain duties is not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.
Finding 2023-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operati...
Finding 2023-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the projects and related expenses submitted to FEMA for reimbursement. Current Status: In progress. Resolution: Management will develop and implement additional internal controls to ensure documentation is retained to evidence the operating effectiveness of the internal controls. These internal controls will ensure expenses included in FEMA grant applications are reported completely and accurately. The additional internal controls will include a reconciliation of application expense detail to final paid invoices along with a notation that each expense is allowed to be included in the FEMA submission. The reconciliation will be reviewed and approved by the Cottage Health Director of Finance prior to final FEMA submission and evidence of the review will be retained. Contact Person: Lawrence Thomas, Director of Corporate Finance Anticipated Completion Date: November 29, 2024
Finding 498294 (2023-006)
Significant Deficiency 2023
City staff will contact all Community Based Organizations (CBOs) that received Emergency Rental Assistance 2 funding to determine if they were required to complete a Single Audit per the Single Audit Act. This communication will include, if applicable, a request that they submit the organizations mo...
City staff will contact all Community Based Organizations (CBOs) that received Emergency Rental Assistance 2 funding to determine if they were required to complete a Single Audit per the Single Audit Act. This communication will include, if applicable, a request that they submit the organizations most recent audit for review by staff. Should a Single Audit identify any findings or other deficiencies, staff will ask the CBO to provide an update as to the status of the deficiency and if it has been appropriately addressed. Staff will document this communication in the electronic file of the CBO who was required to complete a Single Audit.
The Human Services Department The Human Services Department has acknowledged the issue identified regarding timesheet pre-approvals and will take immediate steps to address the issue. HSD will ensure that proxy timesheet approvers are properly assigned in cases where the primary supervisor is unavai...
The Human Services Department The Human Services Department has acknowledged the issue identified regarding timesheet pre-approvals and will take immediate steps to address the issue. HSD will ensure that proxy timesheet approvers are properly assigned in cases where the primary supervisor is unavailable on the day payroll approval is due. HSD will maintain compliance with payroll policies and ensure the accuracy of timesheet approvals. Office of Housing The Office of Housing has acknowledged the finding regarding timesheet pre-approvals and will take immediate steps to address the issue. Office of Housing will ensure that proxy timesheet approvers are properly assigned in cases where the primary supervisor is unavailable on the day payroll approval is due. This adjustment will be incorporated into the previous improved practices, eliminating the need for pre-approving timesheets. By ensuring that proxy approvers are in place, the department will maintain compliance with payroll policies and ensure the accuracy of timesheet approvals. Parks and Recreation Department The Parks and Recreation Department acknowledges the finding regarding timesheet preapprovals and will ensure that proxy timesheet approvers are assigned moving forward as part of the department's ongoing commitment to improved practices. In addition, the department would like to clarify that the pre-approval noted occurred before the implementation of the current corrective action plan, which addressed the prior year's finding. The department reassures the State Auditor's Office (SAO) that the newly adopted practices, which prevent preapprovals, will continue to be strictly followed, ensuring compliance and accuracy in payroll processing, even during pay periods that coincide with holidays.
View Audit 321037 Questioned Costs: $1
Finding 498244 (2023-006)
Significant Deficiency 2023
The City will develop policies and procedures to ensure that all federal reporting is done timely and accurately. Also, those policies and procedures should ensure that these reports are independently reviewed before submission.
The City will develop policies and procedures to ensure that all federal reporting is done timely and accurately. Also, those policies and procedures should ensure that these reports are independently reviewed before submission.
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