I would want to see an explaination on the cause of the finding from the school/department, an solution to the finding and any progress made since the finding.
It should include the steps that will be put in place to correct the findings and to avoid future findings. Updated policies or procedures should be included, if applicable.
In addition to the detail of events and when they occurred, the corrective action plan should provide relevent comments on the detailed action taken to correct any deficiencies from the audit findings. It would aso be a good idea to include projected completion dates for all items that have not yet been implemented.
Elyse - There are also some lists provided in the Additional Resources section for your reference.
I am in the same situation than Beth. I am new to the business and I will have to start working this month on the respond to our last external audit. Richard’s list will be a great help for me as well as all the comments posted in this discussion. Thank you all!
Karen - I completely agree that it's important to keep internal audit going proactively instead of reacting to problems.
The most important thing is that the process is put into place and kept in place. Internal audits should not be started when times are bad and then stopped when the heat is off. They need to be a mandatory action item for each campus to complete annually.
Date Finding Reported
Date Response Submitted
Additional Information Requested in finding(if applicable)
Date Additional Information was provided
Identification of Campus and/or Department Responding
Identification of individual preparing the Response
Statement of Specific Finding for which Response is submitted
Steps required for restitution (if applicable)
Date restitution accomplished (if applicable)
Actions/Circumstances that contributed to finding
Procedure/Policy developed to resolve issue raised in finding
Date of implementation of Corrective Procedure/Policy developed
Monitoring System designed to ensure continued compliance
Department responsible for monitoring activity
Individual(s) with direct responsibility for monitoring activity
Reporting required to demonstrate continued compliance (if applicable)
Target dates for report generation/submission (if applicable)
Very thorough list and good information!
Jennifer - I agree with you - Internal audits should be welcomed versus resisted as it should produce better external audits.
I feel that internal audits are a sure way to ensure that there will be less findings.
Exactly...I am also in agreement. The objective ultimately is to ensure the finding is corrected and that a policy is put in place to prevent future findings.
I am in agreement that the action plan should include those items found to be problematic by the auditors. The plan should address these specific issues and detail steps that are being taken and will be taken as far as corrective measures to prevent the findings from being issues in the future and keep the institution in compliance based on the department's guidelines.
Richard, this is an excellent list!!
When a finding has been identified, a departmental action plan put in place, corrective actions taken, and follow-up occurs ... somewhere in the process, particularly for large departments, there should be staff training, or retaining, to ensure everyone understands the finding and the response.
Thanks Jesse and Courtney! Absolutely, as schools grow, effective delegation to department managers is crucial; that being said, we must make sure that the job expectations for our managers are clearly defined, that the necessary resources to do the job are identified and available, and that we empower our managers to envision, plan, decide, implement and evaluate those actions necessary to effectively lead their departments.
Jay Hollowell
CM101 Guest Facilitator
I totally agree with Courtenay. Each Dept. Manager should fully understand their function as we'll as other dept functions. As a Shool Owner, we sometimes feel that if we want to accomplish something we shoud do it ourselves. Thats okay when you first start your school, but after years and hundreds of students, delegating and proper function education for the staff is a must.
Yes, Catherine. the validation of correction is critical and all employees need to have compliance as part of their responsibilities as it hits all departments.
Great lists - It is important that the staff become involved with the corrective action plans and understand the importance to the company of compliance and follow through. Monitoring proof of correction and post audit testing is important. The use of audit spreadsheets is helpful and criteria reviewed on a regular basis.
If there was an admissions department audit, and there were non-compliant findings with respect to marketing materials, a corrective action plan must include the submission of new marketing materials (ie. print ads, flyers, direct mail packages etc.)proposed for future use that demonstrate compliance.
I concur with Richard's list. I would also emphasize "white paper" or evidence based documentation. Some type of plan or template demonstrating corrective action. Of course, this depends upon the violation/recommendation however, EVIDENCE is critical to this process.
