Corrective Action Plans

Finding 567666 (2024-019)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

Finding 2024-019 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS discussed the change management documented requirements with the information t...

Finding 2024-019 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS discussed the change management documented requirements with the information technology (IT) contractor during April 2025 to ensure all testing is documented appropriately. MDHHS has updated the Michigan Women, Infants, and Children Information System (MI-WIC) Change Management Controls process to include a review of each change to ensure it has successfully completed all components of the change management process prior to completion of associated release activities. Anticipated Completion Date Completed Responsible Individual(s) Kristina Brady, MDHHS Bagya Kodur, MDHHS

View Audit 360209

Finding 567659 (2024-006)

Significant Deficiency 2024

State of Michigan

MI

Special Tests & Provisions Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Finding 2024-006 ADP Security Program Management Views Although MDHHS and DTMB agree annual testing was not conducted for one system and not all necessary updates to the system security plan were completed during the audit period for four systems, MDHHS and DTMB disagree that effective controls wer...

Finding 2024-006 ADP Security Program Management Views Although MDHHS and DTMB agree annual testing was not conducted for one system and not all necessary updates to the system security plan were completed during the audit period for four systems, MDHHS and DTMB disagree that effective controls were not implemented to ensure confidentiality, integrity, and availability of its automated data processing (ADP) information systems. MDHHS and DTMB also disagree that the security of critical systems was at risk by failing to mitigate potential vulnerabilities as described in the effect statement of the finding. MDHHS and DTMB have compensating controls in place to ensure confidentiality, integrity, and availability of its ADP information systems in addition to mitigating potential vulnerabilities. MDHHS and DTMB monitor remediation of Plans of Actions and Milestones for all information systems even after expiration of the authority to operate (ATO). For one system cited, MDHHS is required to audit the system as part of the responsibilities related to the Affordable Care Act and the Medicaid Expansion marketplace. Those audits are conducted to show compliance with federal information security and privacy requirements related to data stored in those systems. The system required to be audited as part of the Affordable Care Act, along with two other systems cited, are reviewed biennially through the Internal Control Evaluation process where control evidence is updated to demonstrate the effectiveness of controls. Each system cited did not have any significant changes and implemented controls are still working as expected. Planned Corrective Action DTMB has hired additional resources to help ensure the timely completion of the required work below. For part a., MDHHS and DTMB will conduct testing of the disaster recovery plan (DRP) by September 30, 2025, and will follow SOM Technical Standards on DRP testing going forward. For part b., MDHHS and DTMB will complete the necessary updates to the system security plans, including updating the risk assessments, and anticipate completion for all cited systems by July 1, 2025. MDHHS and DTMB anticipate that ATO renewals will be attained for all cited systems by August 30, 2025. Anticipated Completion Date a. September 30, 2025 b. August 30, 2025 Responsible Individual(s) Laura Visser, MDHHS Nathan Buckwalter, DTMB Lyndia Deromedi, MDHHS Heather Frick, DTMB Kasi Hunzinger, MDHHS Veronica Maxson, MDHHS Karen Scott, MDHHS Michelle Smith, MDHHS

View Audit 360209

Finding 567657 (2024-004)

Significant Deficiency 2024

State of Michigan

MI

Internal Control / Segregation of Duties § 200.303

Finding 2024-004 Bridges Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS change control processes require a communication to be sent within three business days after each release that validates the changes to Bridges were applied as expect...

Finding 2024-004 Bridges Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS change control processes require a communication to be sent within three business days after each release that validates the changes to Bridges were applied as expected and this validation is documented and retained as part of the release close-out process. MDHHS added a checklist to immediate releases during April 2025 to help eliminate human error and ensure documentation of all post-implementation approvals is retained for each release. Anticipated Completion Date Completed Responsible Individual(s) Holly Roderick, MDHHS

View Audit 360209

Finding 567656 (2024-003)

Material Weakness 2024

State of Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.303

Finding 2024-003 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role except...

Finding 2024-003 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals, semi-annual review of privileged users, and annual review for all users. Security management and access control processes will continue to be a standing agenda item for ongoing quarterly training sessions with Local Office Security Coordinators (LOSCs). For parts a., c., and d., the Access Management Section began conducting quarterly reconciliations of DSA to the Bridges Integrated Automated Eligibility Determination System (Bridges) during the first quarter of fiscal year 2025. For part b., MDHHS is currently evaluating the feasibility of establishing a quarterly review process to help ensure documentation is maintained for a sample of LOSC monitoring reports. MDHHS anticipates completing the evaluation by September 30, 2025, and will determine an anticipated completion date for implementation, if necessary, at that time. For part e., MDHHS Local Office Directors, District Managers, or designees review a monthly sample of high-risk Bridges transactions to ensure documentation was properly maintained. Beginning September 2024, MDHHS Business Service Centers (BSC) implemented a monitoring process to ensure monthly reviews are completed by the local offices timely and that the documentation is properly maintained. Anticipated Completion Date a., c., d., and e. Completed b. September 30, 2025 Responsible Individual(s) a., b., c., and d. Jim Bowen, MDHHS e. Veronica Maxson, MDHHS

View Audit 360209

Finding 567655 (2024-002)

Significant Deficiency 2024

State of Michigan

MI

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.334

Finding 2024-002 Bridges Interface Controls Management Views DTMB disagrees with the condition and the effect of the OAG’s finding. The OAG sampled 85 total files across eight interfaces. Of these, seven appeared to present issues. For five of the sampled files, detailed exception results no longer...

Finding 2024-002 Bridges Interface Controls Management Views DTMB disagrees with the condition and the effect of the OAG’s finding. The OAG sampled 85 total files across eight interfaces. Of these, seven appeared to present issues. For five of the sampled files, detailed exception results no longer existed. DTMB maintains summary tables for 10 years and purges detailed exception records at the beginning of each calendar year for anything older than 12 months. This purge process was communicated to the OAG during the fiscal year 2022 audit, and sampling was performed prior to purging for the fiscal year 2023 audit. When informed that the sample included files for which the detailed exception records had been purged, the OAG requested DTMB run a simulation processing of the original interface file in a testing environment to recreate detailed exception records. DTMB’s technical teams informed the OAG that rerunning in the current test environment would likely differ from the original results due to code changes that occurred in the test environment subsequent to when the original interface files were run in production. The OAG requested DTMB to proceed with rerunning the files in the current test environment. As a result, the OAG identified five instances where the detailed exception records from the simulation in the test environment did not exactly match the summary table from the original production interface results. For the 2 remaining files out of 85 (2.4 percent) that were cited, it should be clarified that the reconciliation being discussed is not data that was lost or misplaced between systems, but reconciliation of two exceptions correctly logged and correctly not counted in a summary report because they were alerts during processing, not errors that would be forwarded for review. These results do not present a significant deficiency in the ability of MDHHS to review the detailed exceptions. Also, these 2 records are insignificant when compared to the 11.6 million records processed in the 85 sampled files (0.000001 percent). Therefore, the current controls are reasonable to ensure that data processed from the source system to the receiving system is processed accurately, completely, and timely. Planned Corrective Action DTMB disagrees with the finding and does not intend to take further action. Anticipated Completion Date Not applicable Responsible Individual(s) Nathan Buckwalter, DTMB

View Audit 360209

Finding 567644 (2024-001)

Material Weakness 2024

Neighborhood Housing Services of the Black Hills, Inc.

SD

Reporting Internal Control / Segregation of Duties

Finding #2024-001 – Preparation of Financial Statements and Schedule of Expenditures of Federal Awards (SEFA) and Audit Adjustments Responsible Individuals: Mike Walker (CEO) and Kathleen Burnham (Accountant) Corrective Action Plan: The Organization has accepted the risk associated with requesting t...

Finding #2024-001 – Preparation of Financial Statements and Schedule of Expenditures of Federal Awards (SEFA) and Audit Adjustments Responsible Individuals: Mike Walker (CEO) and Kathleen Burnham (Accountant) Corrective Action Plan: The Organization has accepted the risk associated with requesting the auditors to prepare the financial statements and SEFA and continues to plan for the auditors to prepare the reports. Due to the cost of hiring a full-time replacement staff accountant, the board of directors and management are willing to accept this degree of risk associated with financial statement and SEFA preparation and will assist with additional internal oversight to limit risk accordingly. Anticipated Completion Date: Ongoing

View Audit 360188

Finding 567641 (2024-002)

Significant Deficiency 2024

Tarrant County Samaritan Housing

TX

Questioned Costs Eligibility Significant Deficiency

Finding-002 Eligibility – Significant deficiency in internal control over compliance (Unit Inspection Documentation) Management Response Management acknowledges that this finding resulted in part from an over-reliance on partner organizations for performing initial and annual unit inspections, witho...

Finding-002 Eligibility – Significant deficiency in internal control over compliance (Unit Inspection Documentation) Management Response Management acknowledges that this finding resulted in part from an over-reliance on partner organizations for performing initial and annual unit inspections, without ensuring that full inspection documentation was consistently maintained in internal records. To address this, the following corrective actions have been implemented: •The Leasing Department and Support Services teams are now required to collect and retain copies of all unit inspection documentation (both initial move-in inspections and annual reinspection), even when performed by partner organizations. •A centralized tracking log for unit inspections has been created and will be maintained by the Program Director to monitor inspection status and ensure document retention for each client. •Program staff are required to upload inspection documents to a secure central drive and log inspection completion in the client case management database. •Quarterly reviews will be conducted by the Compliance team to ensure all required inspection documentation is properly retained and accessible. Training on these updated procedures will be conducted on June 10, 2025, with quarterly refresher trainings planned. Responsible Staff: Program Directors and Leasing Manager Implementation Date: June 2, 2025

View Audit 360187 Questioned Costs: $1

Finding 567639 (2024-001)

Material Weakness 2024

Scripps Health and Affiliates

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended S...

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2024 Finding Reference Number: 2024-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of expenditures to support activities allowed or unallowed, allowable costs/cost principles, reporting and special tests and provisions related to amounts reimbursed for the project worksheet as it relates to the FEMA disposition requirements for COVID-19 related supplies. As a result, Management was reimbursed by FEMA for expenditures that were not in compliance with the FEMA disposition requirements which resulted in a questioned costs of $480,606. Corrective Action Plan: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reporting for reimbursement in the FEMA project worksheet comply with the FEMA disposition requirements. Management will work with FEMA to refund the questioned costs and discuss the extent of the additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: June 30, 2025

View Audit 360181 Questioned Costs: $1

Finding 567628 (2024-005)

Significant Deficiency 2024

Hias, Inc.

MD

Internal Control / Segregation of Duties Reporting Eligibility

Views of Responsible Officials: HIAS management accepts the recommendation and is implementing procedures to ensure that FFATA reports are submitted in a timely manner.

View Audit 360178

Finding 567627 (2024-004)

Significant Deficiency 2024

Hias, Inc.

MD

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.213

Views of Responsible Officials: HIAS management accepts this comment and is finalizing a new comprehensive policy on the vetting of contractors and other third parties.

View Audit 360178

Finding 567605 (2024-001)

Significant Deficiency 2024

Farmville Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Name of Contact Person: Wendy Ellis, Executive Director We will implement proper internal control procedures for the Low Rent Public Housing program eligibility requirements. Immediately.

View Audit 360144

Finding 567598 (2024-004)

Significant Deficiency 2024

Young Mens Christian Association of Boulder Valley

CO

Cash Management Reporting Internal Control / Segregation of Duties

Recommendation – We recommend that management ensure that all grant reporting is tracked to ensure future compliance. Views of Responsible Officials and Planned Corrective Actions – Reporting requirements will be tracked to support requirements in the future.

View Audit 360132

Finding 567595 (2024-001)

Significant Deficiency 2024

Young Mens Christian Association of Boulder Valley

CO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure tha...

Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure that access to records continues to be available.

View Audit 360132

Finding 567594 (2024-002)

Significant Deficiency 2024

Housing Authority of Conway

SC

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Name of Contact Person: Sherry Joyner, Executive Director. We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Immediately.

View Audit 360131

Finding 567593 (2024-001)

Significant Deficiency 2024

Housing Authority of Conway

SC

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Name of Contact Person: Sherry Joyner, Executive Director. We will implement proper internal control procedures for the Section 8 New Construction program eligibility requirements. Immediately.

View Audit 360131

Finding 567565 (2024-007)

Significant Deficiency 2024

City of New Haven

CT

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting § 200.303

Finding 2024-007: Reporting – Significant Deficiency over Internal Control over Reporting Assistance Listing Program: Coronavirus State and Local Fiscal Recovery Fund Finding: Per 2 CFR 200.303, recipients are required to establish, document, and maintain effective internal controls that provide...

Finding 2024-007: Reporting – Significant Deficiency over Internal Control over Reporting Assistance Listing Program: Coronavirus State and Local Fiscal Recovery Fund Finding: Per 2 CFR 200.303, recipients are required to establish, document, and maintain effective internal controls that provide reasonable assurance of compliance with Federal statutes, regulations, and award terms. These controls should align with GAO's Standards for Internal Control in the Federal Government and COSO's Internal Control – Integrated Framework. Condition: The City did not maintain documentation supporting the internal control process over the submission of required quarterly reports during fiscal year 2024. Corrective Actions Taken: 1. Establishment of Formal Reporting Controls: The City has developed and implemented a standardized procedure for the preparation, review, and submission of all quarterly reports related to federal awards, including a designated checklist and approval workflow to ensure compliance with reporting deadlines and content accuracy. 2. Documentation and Retention Protocols: All steps in the reporting process are now formally documented, including preparer and reviewer signoffs. Supporting documentation is retained in a centralized location accessible to relevant staff and auditors for verification purposes. 3. Internal Review and Oversight: The Office of Management, Policy, and Grants has assigned responsibility to the Grant Management Team for conducting secondary reviews of quarterly report submissions. This includes validating that internal controls have been followed, and evidence of compliance is documented. 4. Staff Training: Staff involved in federal reporting have received training on the internal control requirements outlined in 2 CFR 200.303, COSO, and GAO Green Book standards to reinforce the importance of documentation and control procedures. 5. Monitoring and Compliance Checks: A quarterly compliance checklist and review process have been instituted to ensure ongoing adherence to federal internal control requirements. Noncompliance will be flagged and reviewed with senior leadership. Contact: Shannon McCue, Director of Management, Policy, and Grant Anticipated Completion Date: January 2026

View Audit 360119

Finding 567561 (2024-002)

Significant Deficiency 2024

City of New Haven

CT

Subrecipient Monitoring HUD Housing Programs Reporting

Finding 2024-002: Significant Deficiency and Noncompliance Finding, Reporting-Annual Program: Lead-Based Paint Hazard Reduction Grant Program Finding: Under the Lead-Based Paint Hazard Reduction Grant Program Terms and Conditions issued by the U.S. Department of Housing and Urban Development, Cit...

Finding 2024-002: Significant Deficiency and Noncompliance Finding, Reporting-Annual Program: Lead-Based Paint Hazard Reduction Grant Program Finding: Under the Lead-Based Paint Hazard Reduction Grant Program Terms and Conditions issued by the U.S. Department of Housing and Urban Development, Cities were required to submit an annual race and ethnic data reporting form HUD-27061 covering the period from July 1, 2022, to June 30, 2023, by January 10, 2024. Based on our testing of the required quarterly and annual reports we determined the annual report was not submitted as required. Corrective Actions Taken: 1. Centralized Compliance Tracking: A comprehensive Grant Policy has been implemented with centralized tracking to monitor grant reporting deadlines and prevent missed submissions. 2. The Office of Management, Policy, and Grants is establishing a Grant Management Team to conduct a secondary review of all reporting-related entries and ensure timely submissions. These actions will be implemented by the end of the next fiscal year, with all policy updates and training completed by October 31, 2025. 3. Health Department: The Health Department and the City’s Internal Auditor are creating Standard Operation Procedures and will train staff by December 31, 2025. 4. Contacts: Shannon McCue, Director of Management, Policy, and Grants; Maritza Bond, Health Director, Anticipated Completion Date: January 2026

View Audit 360119

Finding 567415 (2024-009)

Significant Deficiency 2024

Tullahoma Housing Authority

TN

HUD Housing Programs Special Tests & Provisions Internal Control / Segregation of Duties

2024-009 – ALN 14.850 – Public Housing Operating Fund – Special Tests and Provisions - Depository Agreements Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior managem...

2024-009 – ALN 14.850 – Public Housing Operating Fund – Special Tests and Provisions - Depository Agreements Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action plan is in place to address these weaknesses and deficiencies. Person Responsible for Correction of Finding: Christy Amacher, Executive Director Anticipated Completion Date: September 30, 2025

View Audit 360091

Finding 567414 (2024-008)

Significant Deficiency 2024

Tullahoma Housing Authority

TN

HUD Housing Programs Reporting Internal Control / Segregation of Duties

2024-008 – ALN 14.872 – Public Housing Capital Fund Program – Reporting Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action plan is ...

2024-008 – ALN 14.872 – Public Housing Capital Fund Program – Reporting Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action plan is in place to address these weaknesses and deficiencies. Person Responsible for Correction of Finding: Christy Amacher, Executive Director Anticipated Completion Date: September 30, 2025

View Audit 360091

Finding 567397 (2024-005)

Material Weakness 2024

Washington Parks Academy

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • We will ensure all reporting is filed on a timely basis.

View Audit 360089

Finding 567395 (2024-002)

Significant Deficiency 2024

Mid-East Regional Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Name of Contact Person: Lynn Alligood, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. Immediately.

View Audit 360080

Finding 567394 (2024-001)

Significant Deficiency 2024

Mid-East Regional Housing Authority

NC

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Name of Contact Person: Lynn Alligood, Executive Director Corrective Action: We will implement proper internal control procedures for the Section 8 New Construction program eligibility requirements. Immediately.

View Audit 360080

Finding 567386 (2024-002)

Material Weakness 2024

Guild

MN

Special Tests & Provisions HUD Housing Programs Material Weakness

Finding 2024-002 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Passed through Hearth Connections and Passed through Dakota County, Continuum of Care. Assistance Listing Number: Federal Financial Assistance Listing #14.267 Program Name: Continuum of Care Progr...

Finding 2024-002 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Passed through Hearth Connections and Passed through Dakota County, Continuum of Care. Assistance Listing Number: Federal Financial Assistance Listing #14.267 Program Name: Continuum of Care Program Finding Summary: Guild’s controls did not operate as designed, which resulted in rent reasonableness tests not being performed timely and/or reviewed before the rent being paid. Corrective Action Plan: This clinical program is now under new leadership and is enhancing its controls and oversight. In addition to requiring a monthly rent checklist to be reviewed and signed off by the responsible official, an additional layer of control will be implemented by involving Finance in verifying that proper documentation is in place before rent checks are issued. The program, in collaboration with Finance, will also continue enhancing the approach to standardized documentation. Responsible Individuals: Keith Rachey - Chief Financial Officer, Tiffany Yang – Controller, Diana Harris – Director of Clinical Services Anticipated Completion Date: Completed by September 2025

View Audit 360077

Finding 567385 (2024-002)

Significant Deficiency 2024

Peabody Housing Authority

MA

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

2024-002 – REPORTING Auditee’s Response and Planned Corrective Action The Executive Director will work with the Fee Accountant in order to review and enhance year end close processes to ensure accuracy and timeliness of reporting. Planned Implementation Date of Corrective Action: June 30, 2025 Per...

2024-002 – REPORTING Auditee’s Response and Planned Corrective Action The Executive Director will work with the Fee Accountant in order to review and enhance year end close processes to ensure accuracy and timeliness of reporting. Planned Implementation Date of Corrective Action: June 30, 2025 Person Responsible for Corrective Action: Anne Marie Burns, Executive Director

View Audit 360060

Finding 567383 (2024-009)

Material Weakness 2024

Housing Authority of Alto

TX

HUD Housing Programs Internal Control / Segregation of Duties

2024-009. SEMAP Supporting Documentation Corrective action planned: Revised control procedures and checklist system for future SEMAP submissions with backup file requirements. Updated ADMIN plan to enforce Quality Assurance procedure, to be performed quarterly. Contact person: Candice Ivory, Exe...

2024-009. SEMAP Supporting Documentation Corrective action planned: Revised control procedures and checklist system for future SEMAP submissions with backup file requirements. Updated ADMIN plan to enforce Quality Assurance procedure, to be performed quarterly. Contact person: Candice Ivory, Executive Director / Deputy Director Anticipated completion date: May 31, 2025/ Ongoing Monitoring

View Audit 360052

Corrective Action Plans

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