Corrective Action Plans

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The local ministry has added an additional question to the intake packet and process to affirm CDC qualification. Additionally, the local Health Ministry program coordinator will include a certification that all participants meet the CDC qualifications, explicitly listed on the cohort data and reimb...
The local ministry has added an additional question to the intake packet and process to affirm CDC qualification. Additionally, the local Health Ministry program coordinator will include a certification that all participants meet the CDC qualifications, explicitly listed on the cohort data and reimbursement form submitted to System Office quarterly.
We determined this understatement was a unique occurrence that made it through our existing controls due to the site?s program and finance leads submitting an estimated benefit amount rather than the actual amount recorded in the general ledger. The Program Manager conducted training with the progra...
We determined this understatement was a unique occurrence that made it through our existing controls due to the site?s program and finance leads submitting an estimated benefit amount rather than the actual amount recorded in the general ledger. The Program Manager conducted training with the program and finance leads for the Fort Lauderdale site to reinforce their understanding of the grant program?s local site control policies. At the Corporation?s System Office, we have enacted a policy requiring that all Health Ministries provide a cost center or a general ledger report to support payroll costs that are accounted for separately from a time and effort report. This will allow us to independently validate these types of expenses in the future and not rely on local site validation as we have in the past.
The Patient Business Service centers are actively reviewing any potential HRSA credits to ensure refunds are processed timely. As the HRSA program has concluded, our teams are now focusing our efforts on reviewing previous HRSA payments to ensure accuracy and that any refunds identified are processe...
The Patient Business Service centers are actively reviewing any potential HRSA credits to ensure refunds are processed timely. As the HRSA program has concluded, our teams are now focusing our efforts on reviewing previous HRSA payments to ensure accuracy and that any refunds identified are processed timely.
Since the beginning of the pandemic, a better understanding of the criteria for qualifying as a COVID-19 related expense has been developed and communicated to colleagues.
Since the beginning of the pandemic, a better understanding of the criteria for qualifying as a COVID-19 related expense has been developed and communicated to colleagues.
CORRECTIVE ACTION PLAN October 2, 2022 U.S. DEPARTMENT OF EDUCATION U.S. DEPT. OF AGRICULTURE Purdy School District R-II respectfully submits the following corrective action plan for the year ended June 30, 2022. Contact information for the individual responsible for the corrective action: Dr T...
CORRECTIVE ACTION PLAN October 2, 2022 U.S. DEPARTMENT OF EDUCATION U.S. DEPT. OF AGRICULTURE Purdy School District R-II respectfully submits the following corrective action plan for the year ended June 30, 2022. Contact information for the individual responsible for the corrective action: Dr Travis Graham, Superintendent Purdy School District R-II 201 Gabby Gibbons Dr Purdy, MO 65734 (417) 442-3215 Independent Public Accounting Firm: The CPA Group, PC, 217 4th Street, Monett, MO 65708 Audit Period: Year ended June 30, 2022 The findings from the June 30, 2022, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS ? FINANCIAL STATEMENT AUDIT Material Weakness ? Internal Control over Financial Reporting - Segregation of duties Finding 2022-001 Recommendation: We realize Because of limited resources and personnel, management may not be able to achieve a proper segregation of duties; however, our professional standards require that we bring this lack of segregation of duties to your attention in this report. Action Taken: The limited number of available personnel prohibits segregation of incompatible duties and the District does not have the resources to hire additional accounting personnel. Completion Date: Not applicable Sincerely, Dr Travis Graham, Superintendent Purdy School District R-II
2022-002 Special Tests and Provisions - SEMAP Housing Voucher Cluster Other matter required to be reported in accordance 2 CFR 200.516(a) Condition: During our audit of the Authority?s SEMAP submission and discussion with the Authority staff, we noted that the Authority did not have proper docume...
2022-002 Special Tests and Provisions - SEMAP Housing Voucher Cluster Other matter required to be reported in accordance 2 CFR 200.516(a) Condition: During our audit of the Authority?s SEMAP submission and discussion with the Authority staff, we noted that the Authority did not have proper documentation to support the selections made for the Authority?s annual SEMAP submission. Auditor?s Recommendations: The Authority should prepare and keep documentation to clearly outline the testing performed as a part of the SEMAP submission and the conclusion of each testing items. Action Taken: Effective July 3 the Authority has required the HCV manager to take steps to ensure the documentation is maintained that clearly outlines the testing performed as part of the SEMAP submission.
2022-004 Procurement/Suspension and Debarment Federal agency: U.S. Department of Agriculture Federal program title: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.556, and 10.559 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-0550-000 Award P...
2022-004 Procurement/Suspension and Debarment Federal agency: U.S. Department of Agriculture Federal program title: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.556, and 10.559 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-0550-000 Award Period: July 1, 2021 - June 30, 2022 Type of Finding: ? Material weakness in internal control over compliance Recommendation: We recommend the District implement procedures and controls to ensure proper procurement procedures are being followed and vendors are not suspended or debarred. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The District will continue to work on establishing procedures and controls to ensure proper procurement procedures are being followed and vendors are not suspended or debarred. Name of the Contact Person Responsible for Corrective Action Plan: Margie Thieschafer, Business Manager Planned Completion Date for Corrective Action Plan: June 30, 2023
Federal Award Findings and Questioned Costs (continued) Finding: 2022-003 Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management?s Response: Congregate Nutrition ? Second Party Review Process The following Second Party Review process was implemented July 2022:...
Federal Award Findings and Questioned Costs (continued) Finding: 2022-003 Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management?s Response: Congregate Nutrition ? Second Party Review Process The following Second Party Review process was implemented July 2022: Each month the Business Manager reviews two completed CRFs for each SMO site. The two CRFs that are selected from a site should be different types (example: one new CRF and one annual re-assessment, or one annual re-assessment and one termination). There is a spreadsheet where these audits are tracked in the secure SNS Z:drive. It will be stored by fiscal year then Internal Audit then SMO Audit Log. In the spreadsheet, the Business Manager enters the site, the first and last name of the client, the review/audit date, and site. In addition, the following items will be reviewed and documented: ? Dates Match: new registration date or change of information date is included and matches date on the back at the bottom of the document - key date ? Type of CRF: new/returning/annual/change/termination ? Term. Reason: if terminated, the termination date and reason are both indicated ? Complete: all boxes/sections are completed or marked refused to answer if option available ? Signed: CRF is signed by both client and site supervisor ? Timely: update is completed each year (indicated on the bottom of the back page) during the same month that the client started unless there is a change of information ? Electronic Signature of person completing internal review: first initial, last name (types in excel sheet) Second party reviews with checklists and reviewer signatures were already in place for remaining Aging Cluster services. Proposed Completion Date: Immediately and ongoing.
Federal Award Findings and Questioned Costs Finding: 2022-001 Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management?s Response: Agency agrees with the finding and will ensure random reviews of workstations will be completed. Agency will ensure immediate refreshe...
Federal Award Findings and Questioned Costs Finding: 2022-001 Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management?s Response: Agency agrees with the finding and will ensure random reviews of workstations will be completed. Agency will ensure immediate refresher in Unit meetings regarding computer security. Additionally, County DSS will continue with an annual training to review computer security and will ensure computer security is addressed in new employee orientation. Proposed Completion Date: Immediately and ongoing.
October 22, 2022 Finding Number: 2022-002 ? Reporting Condition: Meals claimed were not supported by count sheets for either breakfast or lunch for the two months meals were tested prior to MDE site visit. Responsible Person: Stephen Grubaugh ? Director of Business Services Implementation Da...
October 22, 2022 Finding Number: 2022-002 ? Reporting Condition: Meals claimed were not supported by count sheets for either breakfast or lunch for the two months meals were tested prior to MDE site visit. Responsible Person: Stephen Grubaugh ? Director of Business Services Implementation Date: 10-22-2022 During the single audit, it was discovered that Bullock Creek Food Service Department meals claimed were not supported by count sheets for either breakfast or lunch for the two months meals were tested prior to MDE site visit. To ensure that this did not continue, Bullock Creek Food Service and the Technology Department worked together to implement the use of Skyward to track the melas served to students. This transition occurred over a few months, as the implementation was rolled out to 5 individual buildings. When MDE came on campus and audited the months during the transition and found a few discrepancies whish were remedied in the software and the claims were adjusted. RPC then audited the month following the MDE reviews and found no discrepancies. Skyward was used for the rest of the year. For the 2022-2023 Scholl year, the Food Service Department may purchase Meal Magic, which is a food Service software that will streamline the recording and reporting processes even more and may reduce the chance of errors even further. Sincerely, Stephen Grubaugh Director of Business Services
October 22, 2022 Finding Number: 2022-001 ? Excess Fund Balance In Food Service Fund Condition: As of year-end the District had a fund balance in the non-profit food service fund in excess of three months? operating expenses by approximately $85,951. Responsible Person: Stephen Grubaugh ? Dir...
October 22, 2022 Finding Number: 2022-001 ? Excess Fund Balance In Food Service Fund Condition: As of year-end the District had a fund balance in the non-profit food service fund in excess of three months? operating expenses by approximately $85,951. Responsible Person: Stephen Grubaugh ? Director of Business Services Implementation Date: 7/1/2022 During the single audit, it was discovered that Bullock Creek Food Service Department had an excess fund balance in the Food Service Fund by approximately $85,951. This was due to the meal reimbursement rate exceeding the food cost to prepare the meals. All meals served to students during the 2021-2022 school year were provided free of charge to the students, due to grants. In order to reduce the excess fund balance, the district created a spend down plan for the 2022-2023 Fiscal Year. The kitchen at Bullock Creek Elementary needs some structural repairs completed due to faulty roof drainage. The total cost of the project is approximately $73,000. Construction on the project was started in July of 2022 and finished in August. Meal Magic will be implemented during the 2022-2023 School year for tracking of the meal purchases of students and staff. This software will cost approximately $3,000 in the first year to implement and $6,000 in subsequent years. The reaming $10,000 in excess fund balance will be retained, in order to aid in the paydown of potential negative student food service account balances. Since students haven?t paid for breakfasts or lunches for the past 2 years, it is unknown how the many will families will have feel a financial burden paying for their children?s school meals. Sincerely, Stephen Grubaugh Director of Business Services
This is a plan of action that we, as a district, will be implementing in order to correct the Federal finding from our audit. ? 2022-001 - Arkansas DESE Child Nutrition Unit will be contacted for guidance before any transfer to or from Food Services to ensure Ark. Code is followed regarding the Chil...
This is a plan of action that we, as a district, will be implementing in order to correct the Federal finding from our audit. ? 2022-001 - Arkansas DESE Child Nutrition Unit will be contacted for guidance before any transfer to or from Food Services to ensure Ark. Code is followed regarding the Child Nutrition Program. Deanna Clifton, District Treasurer, will contact DESE Child Nutrition Unit to obtain guidance in any action needed regarding the transfer made in Fiscal 2021/2022. Anticipated Completion Date March 15, 2023. I trust that I have covered the points discussed. If you have any questions or if further information is needed, please call me at 870-486-5411, ext. 104. Sincerely, Deanna Clifton District Treasurer/Business Manager
View Audit 18845 Questioned Costs: $1
The Penquis Finance Director will ensure fiscal staff are not using any groupings that may exclude program activity that may have closed during the fiscal year. The Finance Director will also verify preliminary SEFA Revenues compiled by fiscal staff agrees with agency wide Trial Balance totals. Ad...
The Penquis Finance Director will ensure fiscal staff are not using any groupings that may exclude program activity that may have closed during the fiscal year. The Finance Director will also verify preliminary SEFA Revenues compiled by fiscal staff agrees with agency wide Trial Balance totals. Additional training for the Financial Analyst will be provided to include a cross check of department reports to ensure all of the fiscal year data is collected. Expected completion date of June 30, 2023. Responsible official: Denice Conary, CFO (207) 973-3500
2022-003 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: The County should enhance its procedures and internal controls regarding preparation of the Project and Expenditure Reports to ensure that information reported is accurate and agrees to support...
2022-003 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: The County should enhance its procedures and internal controls regarding preparation of the Project and Expenditure Reports to ensure that information reported is accurate and agrees to supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: : New Castle County self-reported the variances in expenditures and obligations due to accruals of costs to previously reported quarters. Such variances can be common with just-in-time reporting. Regarding the omitted projects, the Reporting Portal has undergone several updates throughout the period of performance. These updates contributed to confusion in required data for projects. The omitted projects were included in the subsequent reports after the data points were known and tracked. Regarding the reporting of project obligations, Treasury?s definition of obligation is very broad and FAQ 13.17 allows the recipient to use its discretion to determine when an obligation is incurred. Such discretion calls for the interpretation of several source documents. In each report total obligations were not less than total expenditures nor did total obligations exceed available funding. Name(s) of the contact person(s) responsible for corrective action: Benjamin Morris-Levenson Planned completion date for corrective action plan: June 30, 2023
2022-004 Community Development Block Grant/Entitlement Grants ? Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the County develop controls and procedures to ...
2022-004 Community Development Block Grant/Entitlement Grants ? Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met. We further recommend the County develop controls and procedures to ensure that all required subawards are reported accurately and timely to FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Department of Community Services is developing the following internal controls to ensure that FFATA reporting requirements are met. A system has been created to ensure all required sub-awards are reported accurately and timely in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The following actions have been taken to ensure future compliance FFATA reporting requirements: ? DCS Fiscal Staff is creating an account within the FSRS system on March 27, 2023 ? DCS Grant Management Staff visited the FSRS site to research the data needed to report ? DCS Grant Management Staff created a document outlining the subaward entity information needed. Any entities receiving a sub-award of $30,000 or more will have this document attached to their Funding Award Letter. The FFTA Forms must be completed by the entity (signed by their Fiscal Officer) and returned to DCS Grant Management staff within 10 business days. A contract will not be issued until the completed FFTA Form is received. ? When the entity returns the completed FFATA Reporting Form to the DSC Grants Department, staff will forward a copy to DCS?s Fiscal Department. DCS?s Fiscal staff will enter the information into the FSRS. A contract will then be sent to the entity. ? DCS Grants Management and Fiscal Staff will be provided the FFATA/FSTS guidance and educated on the new process DCS has established for FFATA Reporting. ? DCS will have until the end of the month, plus one additional month after an award or sub-award is made to enter the information into FSRS system. The DCS issued agency award letter is the point of reference. Name(s) of the contact person(s) responsible for corrective action: Carrie Casey Planned completion date for corrective action plan: June 30, 2023
Finding: 2022-001 Condition Found: The Organization drew down the FY 2023 Expanding COVID-19 Vaccination grant funds in full upon receipt of the award in the amount of $100,048 in advance of incurring federal expenses. The Organization incurred allowable expenses of $38,940 through December 31, 2...
Finding: 2022-001 Condition Found: The Organization drew down the FY 2023 Expanding COVID-19 Vaccination grant funds in full upon receipt of the award in the amount of $100,048 in advance of incurring federal expenses. The Organization incurred allowable expenses of $38,940 through December 31, 2022. During 2023, management worked with HRSA and was able to submit a budget revision which was approved by HRSA and allowed the Organization to allocate additional expenses incurred in December 2022 in the amount of $61,108 to the grant. Additionally, the Organization had a construction project during 2022 which was primarily funded by the Capital Assistance for Disaster Response and Recovery Efforts grant. During 2022, the Organization drew down the grant award based on 100% of the incurred allowable costs of the project rather than proportionate share of the grant to the total project costs in the approved budget as required by the Uniform Guidance. Individual(s) Responsible for Corrective Action: Andrew Barter, CEO Celeste Pitts, Interim CFO Corrective Action: The management that conducted and recommended these grant activities are no longer with Little Rivers Health Care, and as a result, management is longer influenced by the factors that caused this condition. The new CEO and new CFO are working with third-party technical assistance from our auditors at Berry Dunn for grant administration. Historically, grant tracking was performed singularly by one individual. Grant management is now conducted by the CEO, CFO, and a Grant Administrator with shared information and functionality, including use of grant management-specific resources in our finance and payroll systems. Capital Grants are monitored through a new Construction in Progress General Ledger account and a detailed Excel sheet that has a budget component. In May, LRHC submitted an ECV Extension Budget for our grant number H8GCS47793, and the budget was approved by Travis Wright, HRSA Grants Management Specialist and Carla Clarke, HRSA Project Officer and Investment Oversight Advisor on June 24, 2023. The budget included allowable and allocable costs for activities in the amount of $100,048 that occurred or were obligated in December 2022. These actions corrected the relevant ECV funding concern listed in finding 2022-001 as reported in the Schedule of Findings and Questioned Costs, Year Ended December 31, 2022. Anticipated Completion Date: Education of HRSA drawdown requirements has occurred with the new LRHC CEO and Interim CFO during this current audit period. Tracking functionality in our Finance and Payroll system has been set up and will be fully utilized by the third quarter of 2023.
Management/Owner Response Management agrees with the finding. The resident files are undergoing a 100% file inspection by a separate CRM employee. All deficiencies will be identified and corrected such as items that cannot be re-created.
Management/Owner Response Management agrees with the finding. The resident files are undergoing a 100% file inspection by a separate CRM employee. All deficiencies will be identified and corrected such as items that cannot be re-created.
Management/Owner Response The Board and Management agree with the finding and is taking action to correct the findings and to implement the recommendations. All other corrective actions will be performed and completed by onsite management personnel during the current year.
Management/Owner Response The Board and Management agree with the finding and is taking action to correct the findings and to implement the recommendations. All other corrective actions will be performed and completed by onsite management personnel during the current year.
Finding Number: 2022-003 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Vada Begay, Business Manager and Sylvia Largo, Homeliving Department Supervisor Anticipated Completion Date: February 28, 2022 Planned Corrective Action: Chara...
Finding Number: 2022-003 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Vada Begay, Business Manager and Sylvia Largo, Homeliving Department Supervisor Anticipated Completion Date: February 28, 2022 Planned Corrective Action: Character investigations were not fully conducted. Prior administrator had begun an investigation and certified without completion of adjudication. When this was revealed a full background check was conducted immediately. However, as background checks were requested, the Navajo Nation background check reports took at least 4 months to receive. This delay caused adjudication to not be completed in a timely manner. WRHI is committed to ensuring the safety of students and will conduct timely and thorough character investigations of all employees and those individuals applying for work positions at our Hall. All resulting documentation of investigation is maintained in a confidential manner.
Finding Number: 2022-002 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Vada Begay, Business Manager and Sylvia Largo, Homeliving Department Supervisor Anticipated Completion Date: July 31, 2023 Planned Corrective Action: SF-425s a...
Finding Number: 2022-002 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Vada Begay, Business Manager and Sylvia Largo, Homeliving Department Supervisor Anticipated Completion Date: July 31, 2023 Planned Corrective Action: SF-425s are submitted in a timely manner. During FY22, the previous Business Manager resigned, leaving unfinished work and reconciliations. It was not until November 2021 that the reconciliations were completed and SF-425s submitted to BIE. There were no issues on the submission of SF-425s after receipt. WRHI will implement internal control to close out trial balance to ensure general ledger, financial statements, and notes are free from material misstatements. These changes will allow WRHI to provide all audit information in a timely manner and to secure a Single Audit Report from the auditor for submission of the annual audit 9 months after fiscal year end.
Finding Number: 2022-001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Indian School Equalization 15.042 Education Stabilization Fund 84.425 Contact Person: Vada Begay, Business Manager, Sylvia Largo, Homeliving Department Supervisor, and School Board Members Anticipated Compl...
Finding Number: 2022-001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Indian School Equalization 15.042 Education Stabilization Fund 84.425 Contact Person: Vada Begay, Business Manager, Sylvia Largo, Homeliving Department Supervisor, and School Board Members Anticipated Completion Date: March 31, 2023 Planned Corrective Action: All financial activities were processed per 2 CFR 200.403 to ensure they were allowable, necessary, and reasonable. WRHI as a Tribally Controlled Organization did expend funds under a self-determination contract in support of a residential program servicing students during the COVID-19 pandemic. Management did communicate with the Board to ensure that the proper expenditure of allocated funds for the board was paid out of the Administrative cost grant.
Finding 1: The District did not obtain prior written approval from the Department of Elementary and Secondary Education (DESE) for the purchase of two pieces of equipment with unit costs greater than the $5,000 threshold as required by COM-22- 047. Corrective Action: The District will comply with al...
Finding 1: The District did not obtain prior written approval from the Department of Elementary and Secondary Education (DESE) for the purchase of two pieces of equipment with unit costs greater than the $5,000 threshold as required by COM-22- 047. Corrective Action: The District will comply with all federal purchasing requirements, including obtaining written approval for equipment with unit costs greater than $5,000. Person Responsible for Corrective Actions: Federal Programs Coordinator Completion Date: This practice will go into effect immediately. Supplemental Findings
View Audit 18563 Questioned Costs: $1
Finding 2022-001: COVID-19 Education Stabilization Fund - Higher Education Emergency Relief Fund (HEERF)- Reporting Condition/Context: For the Institutional portion qua1terly reports for the quarters ending December 31, 2021 and June 30, 2022, the Strengthening Institutions Program (SIP) expenditure...
Finding 2022-001: COVID-19 Education Stabilization Fund - Higher Education Emergency Relief Fund (HEERF)- Reporting Condition/Context: For the Institutional portion qua1terly reports for the quarters ending December 31, 2021 and June 30, 2022, the Strengthening Institutions Program (SIP) expenditures were not reported in the section (a)(2). Subsequently, the University corrected the reports and posted to the College 's website. Corrective Action Plan: We have reviewed the finding and while we believe everything was posted in time, we agree the numbers were not in the correct area. We have made the updates to the website, and updated ED with the changes. UIU commits to having the Assistant VP of Enrollment Management monitor reporting requirements, while the Executive Director of Financial Services reviews any changes for accuracy. These two individuals have also been signed up for webinars regarding HEERF funds.
SHIP COVID Testing and Mitigation: Assistance Listing No. 93.155 Recommendation: We recommend that the University review and update current procedures to ensure the program reporting requirements are completed timely and to ensure review of reports are documented. Explanation of disagreement with au...
SHIP COVID Testing and Mitigation: Assistance Listing No. 93.155 Recommendation: We recommend that the University review and update current procedures to ensure the program reporting requirements are completed timely and to ensure review of reports are documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management agrees with the finding and has already implemented a corrective plan. This delay was caused by communication and workflow breakdown resulting from structural change, a change in the mechanism type from previous years, and key staff passing away at a time when the reporting information would be required. With a new award management system implemented, subawards and fully executed subawards are provided in the Cayuse workflow between offices within CHS and to Stillwater via a Cayuse event. Name(s) of the contact person(s) responsible for corrective action: Michael Sauer, Director of Grants, Contracts & Post Award Administration, OSU-CHS Planned completion date for corrective action plan: Spring 2023
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