A corrective action plan should include what caused their to be a finding, identify what needs to be corrected and develop a plan that will prevent the item from being a repeat finding. If the finding was for late refunds I would want to see the current policy the school follows for late refunds, where the area of weakness may be and how they plan to improve the plan to avoid late refunds from happening in the future.
Since repeat findings is part of the top 10 program review and audit findings I would emphasis the importance of implementing the corrective action plan that is created.
Susan,
Your point on process updates is very valuable as it is true that some focus on fixing the specific item versus the root cause that created the finding. I also like your mention of team building and ownership as this also helps with the long term commitment toward any corrections.
Traci Lee
One of the critical items which should be included in the action plan should be processes to ensure the resolution and prevention of the risk area. Merely correcting the issue is not enough. Further steps should be taken to ensure that the processes are corrected to prevent the issue from happening again. It could also be that during this review process other proactive approaches comes to light and could be implemented. Additionally, the action plan should include dates of when certain tasks will be completed and the individuals responsible for the overall project. This provides a timeline and accountability to oversee that the appropriate actions are carried out. This should also be a time for team building and to include everyone in the department to seek solutions. This way there is ownership in the resolution.
Lydell,
The focus on root cause is key to ensure a true "fix" to rectify any problems.
Traci Lee
Very detailed, I would also add root cause evaluation. Identify the root cause and identify the impact that it may have caused during the process. (Root Cause Anaysis)
Jeanne,
I agree that breaking it down into workable parts is useful to ensure resolution through ownership of the various tasks required.
Traci Lee
Items to be included in a corrective action plan should first include a complete description of the problem to be able to break it down into workable parts. A written plan of action, including the amount of time needed to rectify the problem and checks or markers in place to possibly prevent the problem from re-occurring.
We strongly agree with prior posts. We believe timelines and benchmarks are important in the resolution process of a finding. A plan of correction will also be provided including how we will achieve the goal to meet the standards of the agency.
A corrective action plan should designate the person or department responsible for the action. I also think its important to involve that person when developing the corrective action plan, so they are not "surprised" by the action they now have to take. The action plan should be reasonable, well thought out, and attainable.
A corrective action plan should include the plan to correct the items that were listed as corrective items. it could be finacial aid refund errors, employee files and students files
Describe what should be included in a corrective action plan submitted by a campus or department in response to audit findings. Include specific topics/items that you would want to see for each finding.
I would like to make sure I knew the date of the visit/audit
Some specifics of the findings
Who was involved such as the name of the student, instructor or staff member mentioned in the citation?
Explanation or reason of to the issue
Suggestions for improvement or if the issue has been resolved and when
Specific policies or processes that will prevent the issue from re-occurring
Contact information for the all involved
Specific area of the audit that was sited
The corrective action plan should include whether or not the school concurs with the finding and documentation to support their stance or remediation proof the auditors can use to substantiate the finding. I would want to see the department responsible, the reason for the finding, what is being done to fix it, and the number of days needed to fix and how it will be prevented in the future.
I think this is a great list, Richard, and also like the fact that you have included a monitoring system to ensure continued compliance.
Ralph,
I agree on working together but also think there needs to be clear ownership for any follow up tasks to ensure accountability and responsibility.
Traci Lee
I would ensure the following within my corrective action plan.
• Memorandum format.
• Address each area that fell short of the expected standards.
• Address each area and ways to improve them.
• Address the way each area should be corrected.
• Addressed the timeline and expected outcomes for all corrections to be completed.
As manager I would be disappointed that we did not meet the standards but I would strive for our team to correct our shortcomings and to make improvements needed to be successful. I would stress importance of working together, so this would not happen again.
Hi Tracy,
At a minimum the corrective action should:
1) address the root coause of the issue identified. Even though the audit department might provided a recommendation, other alternatives could effectively address the risk situation identified. The corrective action need to be specific actions such as a new review procedure or approval, training, modification of a process flow, new or modification to a information system programming.
2) states clearly who is the responsable party(ies). There might be corrective action that might require the participation of multiple areas. If the case, the corrective action must list the name and position of each responsible parties.
3) specifies a due date. Deadlines self established by the responsible parties increases the commitment with it by the parties who have to accomplish it. Once the period of time is reasonable/accepatble, it establishes clear goals. In addition, this practice provides guidance to the internal audit follow-up procedures. Specifically, per observation the IA can better program when is more appropriate to start a follow-up process in reasonable alignment with managememt.
I would ask for more documentation to support all key measures. You can never have enough supporting documents to show every avenue has been taken to fullfill the needs of a required field.
Peter,
Excellent point that different issues may require a longer term horizon to rectify whereas others may be addressed more promptly. Good suggestion to break them down into these different time frames for corrective action.
Traci Lee
I believe that the corrective actions plan should include and address the specific points found, the reason for non-compliance, and the timeframe to correct the issues.
these can most likely be broken down to short, mid and long term corrections.
some deficiencies may fall into more than one timeframe and therefore can have a quick reaction to become satisfactorily compliant, and then a longer goal of implementing new processes of improvements.
Ceola,
Great point on the contact information! I have seen many schools struggle with processes and policies to ensure having current contact info on students. If anyone reading this has a good "best practice" that works well, please share it here!
Traci Lee
