Corrective Action Plans

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Finding 12236 (2022-001)
Significant Deficiency 2022
Finding 2021-001 Federal program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing 93.498 Statement of Condition During our testing over reporting, we observed management did not have effective internal controls in place to ensure lost revenues reported in th...
Finding 2021-001 Federal program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing 93.498 Statement of Condition During our testing over reporting, we observed management did not have effective internal controls in place to ensure lost revenues reported in the Portal were not duplicated between a subsidiary entity and the parent entity, resulting in an overstatement of lost revenues reported in the Portal. Lost revenues attributable to Coronavirus in the amount of $2,382,081 were reported in both the parent entity?s PRF reports for the general distribution report for Period 2 and for Ashland Community Healthcare Services and Asante Three Rivers, subsidiary entities, targeted distribution reports for Period 2 (i.e., lost revenues were duplicated). Actions Taken and Status As noted within the portal filing summary for the general reporting Period 2, the Corporation?s consolidated lost revenue totaled $113,690,616. Payments from the PRF for Period 1 and 2 totaled $25,713,324 for the consolidated parent, $5,571,616 for Ashland Community Healthcare Services, and $1,810,465 for Asante Three Rivers per Period 2 targeted reports. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the ?condition found? section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions. Person responsible for the implementation of the corrective action plan: Heather Rowenhorst, Chief Financial Officer Asante Health System
Condition: During compliance testing of the District's accounting records to the expenditure reports filed with the Illinois State Board of Education, we noted the District claimed one expenditure of which was not allowable per the budget detail function code, resulting in questioned costs of $279. ...
Condition: During compliance testing of the District's accounting records to the expenditure reports filed with the Illinois State Board of Education, we noted the District claimed one expenditure of which was not allowable per the budget detail function code, resulting in questioned costs of $279. Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Anticipated Date of Completion: 6/30/23. Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools. Management Response: While this grant program was already finalized, the District will consider amending future budgets with ISBE prior to the grant end date.
View Audit 16420 Questioned Costs: $1
Condition: The School District did not comply with the requirements of filing quarterly reports by the due date set by ISBE. Plan: The District will monitor these filing requirements more closely when the filing deadline approaches. Anticipated Date of Completion: 6/30/23. Name of Contact Person: Dr...
Condition: The School District did not comply with the requirements of filing quarterly reports by the due date set by ISBE. Plan: The District will monitor these filing requirements more closely when the filing deadline approaches. Anticipated Date of Completion: 6/30/23. Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools. Management Response: The District will closely monitor upcoming grant filings while continuing to adhere to future reporting deadlines.
Recommendation: Southwell Obligated Group should continue to improve its understanding of the reporting requirements as specified in the USDA loan documents and create a process to ensure reports are submitted in a timely manner. Planned Corrective Action: Southwell Obligated Group will establish a ...
Recommendation: Southwell Obligated Group should continue to improve its understanding of the reporting requirements as specified in the USDA loan documents and create a process to ensure reports are submitted in a timely manner. Planned Corrective Action: Southwell Obligated Group will establish a calendar schedule of key dates and required reports by July 31, 2023. This Calendar will be managed by the Controller and reviewed by the Senior Vice President ? Chief Financial Officer. Reports not previously submitted timely have now been submitted.
View Audit 16400 Questioned Costs: $1
Finding #2022-001: Internal Controls Over Compliance Related to Payroll; Federal Program: Provider Relief Fund (93.498); Response: We will review department documentation of hours allocated to grants; Responsible party: Kevin Sander, Controller; Estimated Completion: The very next payroll submission...
Finding #2022-001: Internal Controls Over Compliance Related to Payroll; Federal Program: Provider Relief Fund (93.498); Response: We will review department documentation of hours allocated to grants; Responsible party: Kevin Sander, Controller; Estimated Completion: The very next payroll submission.
February 10, 2023 Rubino & Company 6903 Rockledge Drive, Suite 1200 Bethesda, MD 20817-1818 Re: Corrective Action Plan to Finding 2022-001 Housing Authority of the City Decatur received the draft audit report for Fiscal Year Ended June 30, 2022. As per your request, this is the Corrective Action Pla...
February 10, 2023 Rubino & Company 6903 Rockledge Drive, Suite 1200 Bethesda, MD 20817-1818 Re: Corrective Action Plan to Finding 2022-001 Housing Authority of the City Decatur received the draft audit report for Fiscal Year Ended June 30, 2022. As per your request, this is the Corrective Action Plan for the finding in Section III ? Federal Award Findings and Questioned Costs. Finding 2022-001 Public and Indian Housing ? Special Test and Provisions ? Wage Rate Requirements Significant Deficiency in Internal Controls Cause: The Authority failed to obtain payroll reports for one of the contracts that required Davis-Bacon wage requirements. Auditor?s Recommendation: We recommend that DHA obtain and review the missing payroll reports from the contractor, and if necessary, follow up on any non-compliance. DHA should also establish procedures to ensure that required payroll reports are obtained for all contracts subject to Davis-Bacon wage requirements. DHA Corrective Action Plan: DHA failed to obtain payroll reports from said contractor. Moving forward Taura L. Denmon, Executive Director or Mechelle Dowdy, Director of Housing will be responsible for receiving and checking Davis-Bacon wage reporting requirements. Staff Contact: Taura L. Denmon, Executive Director Target Completion Date: October 31, 2022 Sincerely, Taura L. Denmon Executive Director
Finding 2022-002 ? Material Weakness ? Preparation of the Schedule of Expenditures Description of Finding: The schedule of expenditures of federal awards and related supporting documentation were not completed in their entirety and available to be audited in a timely fashion as evidenced by a signi...
Finding 2022-002 ? Material Weakness ? Preparation of the Schedule of Expenditures Description of Finding: The schedule of expenditures of federal awards and related supporting documentation were not completed in their entirety and available to be audited in a timely fashion as evidenced by a significant amount of adjustments needed to reconcile the schedule of expenditures of federal awards to the general ledger, grant awards, and confirmation received from funding sources. This caused the single audit completion to be delayed. Statement of Concurrence: Lutheran Social Services agrees with the finding and is putting a corrective action plan in place as described below. Corrective Action: We are currently assessing our staffing and structure to ensure efficiencies in our operations and infrastructure. We are in the process of restructuring our department, this means making appropriate position and structure changes as needed. Name of Lutheran Social Services of New York Contact: Rinku Bhattacharya, CFO, 212-870-1100 Projected Completion Date: 6/30/2023
Finding 2022-003 ? Material Weakness ? Reporting ? Head Start Program Cluster Grantor: U.S. Department of Health and Human Services Federal Program Name: Head Start Program Federal Assistance Listing Number: 93.600 Description of Finding: Lutheran Social Services of New York did not submit require...
Finding 2022-003 ? Material Weakness ? Reporting ? Head Start Program Cluster Grantor: U.S. Department of Health and Human Services Federal Program Name: Head Start Program Federal Assistance Listing Number: 93.600 Description of Finding: Lutheran Social Services of New York did not submit required reports to the New York City Department of Education within the required due date. Statement of Concurrence: Lutheran Social Services agrees with the finding and is putting a corrective action plan in place as described below. Corrective Action: For the period beginning January 1, 2022, HS01 reporting is no longer required. Name of Lutheran Social Services of New York Contact: Rinku Bhattacharya, CFO, 212-870-1100 Projected Completion Date: 1/1/2022
Views of Responsible Officials and Planned Correction Action: The Grants and Business Departments have worked together to create a process with appropriate checks and balances regarding moving expenses across individual grants and major funds. This process will consist of multiple levels of approval...
Views of Responsible Officials and Planned Correction Action: The Grants and Business Departments have worked together to create a process with appropriate checks and balances regarding moving expenses across individual grants and major funds. This process will consist of multiple levels of approval and specific documentation. Any entries will be processed in a timely manner and all expenditure reports will be checked for errors monthly. This process will ensure that expenditure reports are accurate at the time they are submitted for reimbursement.
View Audit 16323 Questioned Costs: $1
Finding 12194 (2022-001)
Significant Deficiency 2022
Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Pr...
Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan The prior year corrective action plans were successful in addressing the issues identified in previous audits in enrollment reporting. These additional steps will be taken to address the new issues found during the 2022 audit within enrollment reporting, which resulted in a repeat finding of 2021-001. Grayson Layton, Registrar, will review the College?s policies and procedures surrounding student enrollment and enrollment reporting, starting in May 2023 specifically as it relates to students that have withdrawn that are expected to return in the subsequent semester but fail to reenroll. Any changes in the College?s policies and procedures will be appropriately documented and communicated to the individuals involved in updating student enrollment information in the system. Additionally, Enrollment Services will work with a PeopleSoft consultant and technical staff to customize our Student Information System to allow for the correct reporting of student status to the National Student Clearinghouse (NSC). Technical staff and a consultant will be engaged to perform an evaluation of all systems and practices related to enrollment reporting. The Enrollment Services and Financial Aid and Scholarships Offices will use various NSC and National Student Loan Data System (NSLDS) error reports to ensure student enrollment information, including program level information, is reported in an accurate and timely manner. Timing Grayson Layton, Registrar, will work with consultants and technical staff starting in May 2023 to begin making necessary adjustments to the Student Information System to allow for accurate reporting of student enrollment information and to evaluate systems and practices related to enrollment reporting. They will meet monthly throughout the year to monitor their progress with an expected completion in December 2023. Grayson and Riley Niemand, Manager of Financial Aid, will coordinate the use of NSC and NSLDS error reports to identify students with reporting errors. This process will be complete in June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109
Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Organization CFO understands the function and necessity of preparing a complete and accurate SEFA. The organization will secure the Grants Management module to use wit...
Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Organization CFO understands the function and necessity of preparing a complete and accurate SEFA. The organization will secure the Grants Management module to use with the accounting software to enhance the ability to efficiently generate the SEFA in a timely manner for the annual audit. The CFO will be reviewing financial records to make sure all cash and noncash federal grants are included on the SEFA.
Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Chief Financial Officer (CFO) understa...
Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Chief Financial Officer (CFO) understands the importance of recording all revenue and deferred revenue to ensure accurate financial accounting and reporting. The Organization has acquired an accounts receivable module for their accounting software to record accounts receivable monthly. The CFO will be reviewing financial records to make sure all revenue and elimination of intercompany transactions are recorded.
Finding 12130 (2022-002)
Significant Deficiency 2022
2022-002: Reporting Requirements Criteria: The Organization is required to submit various reports as listed in each grant agreement for the major program. The Organization submitted two reports after the reporting deadline. Additionally, one required report was not filed. Condition: The Organization...
2022-002: Reporting Requirements Criteria: The Organization is required to submit various reports as listed in each grant agreement for the major program. The Organization submitted two reports after the reporting deadline. Additionally, one required report was not filed. Condition: The Organization did not timely file all reports in accordance with reporting requirements listed in each grant. Questioned costs: None Cause and Effect: By not filing all reports timely, the Organization could face repercussions from the grantors. Corrective Plan: Midwest Food Bank NFP inadvertently missed the reporting deadline due to misinterpreting the reporting requirements. The Organization, led by Lisa Martin, CFO, will establish a framework by June 30, 2023, to more closely identify and track reporting deadlines to ensure reporting within proper timeframes.
Finding Number: 2022-003 ? Reporting Name of Contact Person: Tamara Colden, Assistant Director Housing and Community Services Department Corrective Action: A new administrative staff position was added in Fiscal Year 2022-2023 that is is now responsible for submission in EARS to address timeliness...
Finding Number: 2022-003 ? Reporting Name of Contact Person: Tamara Colden, Assistant Director Housing and Community Services Department Corrective Action: A new administrative staff position was added in Fiscal Year 2022-2023 that is is now responsible for submission in EARS to address timeliness issues. Management staff will take the following steps to ensure new staff are aware of policies established for continued commitment to timeliness: 1. Management staff will review current established timelines with staff responsible for submitting reports including reminders. Proposed Completion Date: 06/30/2023
Views of responsible officials and planned corrective actions: The Organization agrees with this finding. The Chief Financial Officer will prepare the required reports and the Executive Director will review the grant terms and conditions and the draft of the required reports before approving the sub...
Views of responsible officials and planned corrective actions: The Organization agrees with this finding. The Chief Financial Officer will prepare the required reports and the Executive Director will review the grant terms and conditions and the draft of the required reports before approving the submission of the required reports.
Finding 2022-002 Reporting ? The Executive Advocate (Tony Metz) will review newly signed con tracts for programmatic report requirements and enter the due dates into the tracking spreadsheet. ? Each staff member with responsi bility for completing reports will have access to the tracking spreadsheet...
Finding 2022-002 Reporting ? The Executive Advocate (Tony Metz) will review newly signed con tracts for programmatic report requirements and enter the due dates into the tracking spreadsheet. ? Each staff member with responsi bility for completing reports will have access to the tracking spreadsheet document. ? The Executive Advocate will remind the team member responsible for completing the report two weeks before the due date. ? The assigned staff member will complete the report, submit the report, and mark the submission date in the tracking spreadsheet. ? The Execu tive Advocate will be responsible for monitoring th e submission of reports and alerting the Chief Executive Officer prior to any missed deadlin es. This process will be reviewed by the Finance Committee and approved by the Quanada Board of Trustees as part of our Fiscal Policy document.
Federal Grantor: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution All expenditures included by VUMC Management (Management) in its sub...
Federal Grantor: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution All expenditures included by VUMC Management (Management) in its submissions in the Department of Health and Human Services (HHS) portal were verified against HHS guidance to ensure allowability. Management understands that additional audit evidence must be retained at a detailed enough level to allow the auditor to meet their reperformance standard. Management believes that our control risk is mitigated by the fact that our lost revenues far exceed any provider relief funding received. However, should management need to report any future eligible expenses in the HHS portal, we will retain additional audit evidence to enable auditor reperformance of the controls regarding allowability of expenditures. Management also established appropriate review and approval controls surrounding the performance and review of the lost revenue analytic and the subsequent reporting of lost revenue in the HHS portal. Management retained documentation to support execution of this control; however, Management understands that additional audit evidence supporting the reviews was not available to the auditor to evidence execution of this control. Management will retain additional audit evidence to allow the auditor to reperform execution of this control for future HHS portal submissions. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.
Federal Grantor: U.S. Department of Health and Human Services Assistance Listing No.: 93.067, Global AIDS Award Number: 6 NU2GGH001943-05-09 VUMC is a prime recipient of funding from the Centers for Disease Control and Prevention related to the Global AIDS grant and made first tier subawards of grea...
Federal Grantor: U.S. Department of Health and Human Services Assistance Listing No.: 93.067, Global AIDS Award Number: 6 NU2GGH001943-05-09 VUMC is a prime recipient of funding from the Centers for Disease Control and Prevention related to the Global AIDS grant and made first tier subawards of greater than $30,000. VUMC reported the subaward from VUMC, the prime, to Friends in Global Health, the subrecipient, as a single report in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) instead of filing a separate report for each subaward. Procedures and internal controls were in place for first tier subawards. VUMC has changed procedures and internal controls to report each Global AIDS subaward separately in FSRS. All subawards have been reported in FY23 in compliance with the Transparency Act. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.
Corrective Action Plan For: SwedishAmerican Health System Finding number: 2022-001 Description of the finding: Amounts reported as eligible expenses in Reporting Period 2 were overstated by approximately $1,059,100. Corrective actions taken or planned: Lab expenses were erroneously duplicated d...
Corrective Action Plan For: SwedishAmerican Health System Finding number: 2022-001 Description of the finding: Amounts reported as eligible expenses in Reporting Period 2 were overstated by approximately $1,059,100. Corrective actions taken or planned: Lab expenses were erroneously duplicated due to using two sources for COVD-19 lab expenses ? 1) lab expenses internally charged to certain departments, and 2) a summary of lab expenses for all departments. This was discovered in April 2022, after Reporting Period 2 had closed on March 31, 2022. The reporting portal does not allow edits to a prior closed period; therefore, we assessed all received PRF funds against all uses of funds. Reporting Period 1 and 2 we only used expenses; however, we had lost revenue of approximately ($26,783,301) when comparing actual net revenues from April 1, 2020 to June, 30 2020, to the same period April 1, 2019 to June 30, 2019. When subtracting overstated lab expenses of $1,059,100 from Reporting Period 2, this leaves lost revenues of approximately ($25,724,223) to use in in future reporting periods. Reporting Period 3 and Reporting Period 4 we received funds of approximately $17,354,104 which is less than the remaining lost revenue of approximately ($25,724,223). Reporting Period 3 and Reporting Period 4 will only use lost revenues to justify the funds received. If we could correct reporting period 2 we would claim $1,059,100 against lost revenue and reduce the duplicated expense. However, if we receive funds for reporting periods after Reporting Period 4, we will deduct the excess expenses reported from lost revenues remaining to be claimed. Anticipated completion date: 4/18/2022 Person responsible for Corrective Action Plan: Patricia DeWane, CFO and Treasurer, (779) 696-4009 pdewane@uwhealth.org SwedishAmerican Health System, SwedishAmerican Hospital, DBA UW Health
Condition: The School District did not comply with the requirements of filing quarterly and final reports by the due dates set by ISBE. Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Anticipated Date of Completio...
Condition: The School District did not comply with the requirements of filing quarterly and final reports by the due dates set by ISBE. Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Anticipated Date of Completion: June 30, 2023. Name of Contact Person: Colleen McKay, Superintendent. Management Response: The District will review the reporting deadlines and file reports moving forward on a timely manner by the due dates.
Annual Sub-Recipient agreement and Annual Single Audit of Sub-Recipient will be requested. Persons Responsible: Michelle Shedden, Chief Clerk Anticipated Completion Date: Immediately
Annual Sub-Recipient agreement and Annual Single Audit of Sub-Recipient will be requested. Persons Responsible: Michelle Shedden, Chief Clerk Anticipated Completion Date: Immediately
Finding #2022-003 The EPCAMR Executive Director will work closely with our Bookkeeper to ensure the financial statement audit will be completed in a timely manner for fiscal year 2023 and looking ahead to 2024, if a Single Audit is warranted and additional Federal funds are awarded and expensed. In ...
Finding #2022-003 The EPCAMR Executive Director will work closely with our Bookkeeper to ensure the financial statement audit will be completed in a timely manner for fiscal year 2023 and looking ahead to 2024, if a Single Audit is warranted and additional Federal funds are awarded and expensed. In accordance with 2CFR Section 200.512A, EPCAMR will submit the reporting package the earlier of 30 calendar days after receipt of the Auditor’s Report. I have reviewed the audit findings and going forward these findings will be corrected for the 2023 Single Audit, if one is necessary and determined based on Federal expenditure of funds and going forward in 2024, should EPCAMR receive additional Federal funds that would warrant an Single Audit and completion of a SEFA.
Finding #2022-002 The Executive Director and Program Manager will work with our Bookkeeper to report all future Federal expenditures on the Schedule of Expenditures of Federal Awards (SEFA) to ensure accuracy and account for all Federal designated funds. Federal funds documented on the SEFA will all...
Finding #2022-002 The Executive Director and Program Manager will work with our Bookkeeper to report all future Federal expenditures on the Schedule of Expenditures of Federal Awards (SEFA) to ensure accuracy and account for all Federal designated funds. Federal funds documented on the SEFA will allow for the Auditor to be more aware of the need for a Single Audit, should $750,000 in expenses be incurred in a fiscal year. EPCAMR currently tracks those expenditures of funds through monthly Excel sheets that are provided by the PA Department of Environmental Protection that are normally invoiced monthly and approved by the Commonwealth’s Office of Management and Budget before payments are received for and an online grant management system called EasyGrants for our current National Fish & Wildlife Foundation grant where expenses are submitted for approval. Should EPCAMR be awarded future Federal grant funds, they will be added on the SEFA, accordingly, to document expenditures within the given fiscal year. The EPCAMR Executive Director will act as a Grant Coordinator since we do not have additional capacity or funding for another position at this time to identify Federal awards, track expenditures, and to prepare the expenditure of Federal Awards on the SEFA on a yearly basis that will be submitted to the Auditor each year for review. Submission of the SEFA will allow the Auditor to make the determination as to whether or not a Single Audit is necessary.
Name of auditee: Village of New Hartford Section 8 Housing Assistance Payments Program (NY552) TIN: 16-0918009 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2022 - December 31, 2022 CAP prepared by: Amy Turner aturner@mvcaa.com Finding 2022-001 Village of New Hartfor...
Name of auditee: Village of New Hartford Section 8 Housing Assistance Payments Program (NY552) TIN: 16-0918009 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2022 - December 31, 2022 CAP prepared by: Amy Turner aturner@mvcaa.com Finding 2022-001 Village of New Hartford Section 8 Housing Assistance Payments Program (NY552)’s administering agency Mohawk Valley Community Action Agency, Inc., has implemented accounting procedures to ensure proper identification of federal expenditures and timely submission of the data collection form to the Federal Audit Clearinghouse.
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th...
Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with requirements for time-and-effort documentation. Name, address, and telephone of District contact person: Benjamin Rarick, Associate Superintendent of Finance 12033 SE 256th Kent, WA 98031 Corrective action the auditee plans to take in response to the finding: The Grants Administrator, under the supervision of the Director of Budget, will do interim and year-end reviews to identify any instances of positions funded by multiple federal funding sources for the purpose of assessing applicability of multi-cost objective T&E requirements and following through as appropriate. The Grants Administrator, under the supervision of the Director of Budget, and in collaboration with the program administrator, will initiate time & effort documentation in every case where there is debatable fact pattern, with the intent of adopting an “abundance of caution” approach to T&E, and will additionally seek written clarification from OSPI and/or the ESD in instances where T&E requirements are not dispositive from the relevant federal compliance supplements and guidance documents. Anticipated date to complete the corrective action: October, 2024
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