I would quickly correct any issues found, during the audit, to keep my campus compliant. It's important to be prepared for an audit. We always have notice before a visit and preparing for it keeps us organized for the audit.
Isabel,
I think it's great to be prepared - I also think it's good to be organized proactively as sometimes, even if notice is provided, there may not be enough time to completely get things in order if there is a lot to do to organize.
Traci Lee
An action plan should include at minimum the following:
•The description of the failed test.
•The number of exceptions found
•The threshold before the test is considered a fail test
•The detail information of each exceptions.
•The team member directly responsible of each test.
•How the team member will resolve the current issue and the plan to prevent the same item in the future
•The timeline of the implementation, and
•A follow up time line from the audit team.
•Signatures and date
Generally, a corrective action plan not only addresses the individual finding but a response to any systemic issue. The auditor is only reviewing a small sample of all of the activity so when there is a finding it raises the issue that there is a deficiency in the internal policies and controls.
A campus or department should include a specific response to the finding but also a clarification on what changes, if any, they will make to their systems to make sure the finding does not happen again.
John,
Great point - there is a big difference between an isolated error and a systemic problem that requires revising policies and/or processes and procedures.
Traci Lee
I believe this is a pretty comprehensive list!
I am new to becoming the dean at my school, and while being the assistant I was minimally exposed to audits I will be answering to them in the near future.
The school I work for has been in business for over 30 years and I am sure they have this type of detailed list for such matters.
Luckily we have not been sited for many, many years.... (I hope I didn't just jinx myself!)
Thanks, I am taking it all down for future reference.
I would want a description of the original finding. A breakdown of steps to correct this finding and how to avoid this in the future. Once creating a new procedure I would implement it into my operations manual.
Very detailed list. It is very important to have a thorough and clear corrective action plan so it may be a "stand alone" document.
Jennifer,
Well stated - a good audit response can be understood by anyone without knowing the details of this history of the finding/observation.
Traci Lee
It depends on the issue that needs to be corrected.
Short term and vital issues should identify the problem, the source of the problem the reason(s) for the problem and the procedural steps that are to be implemented. Then some reasonable test should be conducted to try to ensure that the correction did take place.
Isssues that are measured over a longer period of time would require all of the above steps, as well as some intermediate steps to encourage progress toward the solution. The intermediate steps should be subject to some reasonable test along with a test of the ultimate goal.
A corrective action plan submitted by a campus in response to audit findings needs to include a summary of the findings with specific action items necessary to correct or respond to each finding.
The specific action items may include new policies and procedures when necessary and will need to include the purpose and responsible positions to uphold the polices and procedures.
Corrective action item will also require a specific timeline for implementation of action or change that lead to the correction right away or over time.
For responses to findings that require formal documentation indicating a finding has been corrected, the "proof" must be comprehensive and applicable.
Any shortcoming should be address in the Corrective Action Plans (CAP). The department head should provide a training program as a way to correct future incidents as part of the CAP.
Every member in that department should realize the shorcoming and a way to prevent future actions.
A Corrective Action Plan for an audit finding should have detailed components to it. If there are multiple findings each finding should should be numbered, have a title for the finding and then a summary of the finding that needs to be rectified.
There should be a response of the corrective action that will take place and how these actions will be implemented.
The responsible person or department should be identified and the due date to be completed.
Procedures should be put in place to prevent the infractions from reoccuring.
Annette,
Great summary of steps to take on a corrective action plan. Then it just requires monitoring and tracking to ensure the responsible individuals meet their deadlines.
Traci Lee
Barbara,
You couldn't be more right with the "explanation showing an understanding of the finding; i.e. what might have caused it." point. This prevents going off on tangents that lead to more and more questions. Last thing I want to do is explain and give background to the audit findings that the auditor should already be aware of. A lingering audit does not reflect well on the department(s).
A corrective action plan should include the individuals that will be working on the audit findings. They would have to be very detailed as in which files and topics they each would be addressing. I do think a timeframe would have to be given for re-evaluation of the corrections and actions that need to to be made. They can also include how the audit findings will not come up as a factor again.
Saradjeen,
Agreed that in addition to fixing the findings, it's important to ensure process modifications to ensure such findings won't occur again.
Traci Lee
The corrective action plan submitted by a campus or department in response to audit findings should include remediation steps to ensure an action plan is in place. For example, steps should be outlined that address potential graduates received proper counseling of field related courses each term. This step would require continuous monitoring of students classes and noting their final grades to ensure the students have satisfied the course requirement with satisfactory grades.
I will use the records department to discuss this corrective action plan.
For each problem that is found resulting from the audit I will want to see a plan of action for how to correct the problem. For example, a notification to our employees in the records department informing of them of the documents that need to be included in a student's file etc. I would also put in place a double check system informing the records department of what forms they need to receive and who to notify if they do not receive it. The party responsible for those forms also needs to be notified to have the forms complete and who to send them to. It is then a higher level person to continually audit both departments and make sure both parties are being held accountable for their work. Internal audits are very important. We cannot expect that once an audit is complete, employees will magically get it right. They have to monitored for some time. A corrective action plan must also have a timeline and deadlines for when the steps involved.
