Puerto Rico College of Physicians-SurgeonsNon-Profit

During the audit the College changed the trial balance figures more than once due to classification errors, transactions not recorded, differences with federal reports, etc. Even though all these changes, remained a difference of $7,102 in the accounting books related to the expenditures reported in FEMA Vaccination Grant DS1374. The difference represents an overstatement of the program expense.

The award agreements require that the program expenses be reasonable and necessary and in compliance with federal regulations. The costs incurred by the College to run the project of the FEMA Vaccination Grant violate the reasonability criteria established by the award agreements and the College procurement policies because it did not carefully document the justification of how the situation created an urgent need to perform the work sooner than a competitive process would allow. The selection of the vendors for supplies, equipment, materials, and services did not go through the College’s existing procurement requirements and the management did not provide adequate information to justify the selection of the vendors without a procurement process.

The FEMA Vaccination grant agreement allowed items for rent, utilities, and phone expenditures in the budget but when we examined the related expenditures, the amounts incurred were not properly supported and the amount paid went over the established budget.

During the examination of several vendors expenditures, we found the following situations from a sample of 120 transactions:

During the examination of employee records of medical staff and other professional, employed under FEMA Vaccination Grant, we found the following situations from a sample of 179 employees

In our examination of the expenditures of FEMA Vaccination Grant during the year 2022 we found the College granted a contract for legal advisory related to FEMA Vaccination Grant to an internal legal advisor of the College. Additionally, the College granted a contract to an external company for the management, accounting, and reporting of FEMA Vaccination Grant where the internal legal advisor is also the Treasurer of the external company, and her husband is the President of the external company. These legal advisory contracts denote a duplicity to the existing contract that the legal advisor has as internal legal advisor of the College and the contracts with the external company present a conflict of interest as defined and established by the Uniform Guidance section 200.318.

In our examination of the expenditures of the FEMA Vaccination Grant during 2022 we noticed the College granted a contract as program medical director to the President of the College. As established by the Uniform Guidance criteria and internal polices of the College these contracts were granted in a clear conflict of interest where an officer of the College is using its position for a private gain.

The College purchased equipment such as laptops, monitors, scanner, servers and refrigerators with federal funds from FEMA Vaccination Grant Program. During the audit, the College did not provide evidence of compliance with requirements established in the criteria section. The College did not prepare a physical inventory of the property and did not maintain records of the property acquired. Additionally, all equipment acquired was handed over to the Pass-through entity at their request and without following the procedures established in section 200.315 of the Uniform Guidance.

The College expended $311,546 in supplies for which it did not maintain an inventory of these. At the end of the project, management reported that there was a significant number of materials that were not used. Upon completion of the project these materials were requested by the pass-through entity and delivered to them. Since there was no inventory of them, the unused inventory on hand of the College and delivered to the pass-through entity could not be quantified.

We observed that FEMA Vaccination Grant monthly reports were submitted late, and the College did not provide evidence of submission of the report named Full Final Reconciliation Report. However, we obtained the Final Closure Report and in that report was informed that all program funds were used. Based on the College accounting records we noticed that not all funds were used, and the College accrued $63,488 of funds that were returned to the pass-through agency on March 31, 2023.

Identifying Number: 2021-001 Federal program:COVID-19 Coronavirus Relief Fund DS0947 & FEMA Vaccination Grant DS1374 CFDA number: 21.019 & 97.036 Federal Agency: U.S. Department of Treasury and Homeland Security Passed through: Puerto Rico Department of Health Compliance requirement: Reporting Identification as a Repeat Finding: Not a Repeat Finding Criteria Grant accounting under US GAAP can be complex and nuanced. Careful evaluation of grant agreements is necessary in order to ensure grants are recorded correctly. Condition During the audit the College changed the trial balance figures more than once due to classification errors, transactions not recorded, differences with federal reports and subsidiaries, etc. Even though all these changes we noticed a difference of $63,258 in professional services expenses of the COVID-19 Coronavirus Relief Fund. The difference was related to tax withholdings at source of several service providers of the COVID-19 Coronavirus Relief Fund DS-0947 project. Context During the 2021 the College due to personnel shortages did not keep adequate control of the accounting of federal grants expenditures instead relied from external service providers who provided to the College with records of the expenses. Effect The error in recording the grant funds that gave rise to the changes to the trial balance resulted in an understatement of the grant expenditures. The difference in professional services resulted in an overstatement of Cares Act Funds under DS-0947. The errors have been corrected in the audited financial statements but are material to the financial statements as a whole and could influence management decisions based on preliminary internal reporting. Cause The accounting department has a staff shortage, coupled with inadequate training in the management of federal grants. This has resulted in errors in grant accounting not being identified and corrected on a timely basis. Questioned costs $0. Recommendation We recommend the College to evaluate the shortage of personnel and hire additional personnel with the necessary skills to help refine its process of evaluating and reconciling the accounting on a timely basis. The existing and new employees must be trained in the management and accounting of federal grants and compliance requirements of the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions Management response is reported in the ?Corrective Action Plan? at the end of this report.

Identifying Number: 2021-002 Federal program: COVID-19 Coronavirus Relief Fund DS0947 & DS1075 FEMA Vaccination Grant DS1374 CFDA number: 21.019 & 97.036 Federal Agency: U.S. Department of Treasury and Homeland Security Passed through: Puerto Rico Department of Health Compliance requirement: Allowable Costs Identification as a Repeat Finding: A Repeat Finding Criteria The award agreement requires that the program expenses be reasonable and necessary. A cost to be allowable needs to be reasonable. Per Uniform Guidance section 200.404 a cost is reasonable if, in its nature and amount, it does not exceed that which would be incurred by a prudent person under the circumstances prevailing at the time the decision was made to incur the cost. In determining reasonableness of a given cost, consideration must be given to among other requirements (a) The restraints or requirements imposed by such factors as: sound business practices; arm?s-length bargaining; Federal, state and other laws and regulations; and terms and conditions of the Federal award (b) Market prices for comparable goods or services for the geographic area (c) Whether the individuals concerned acted with prudence in the circumstances considering their responsibilities to the non-Federal entity, its employees, the public at large, and the Federal government (d) Whether the non-Federal entity significantly deviates from its established practices and policies regarding the incurrence of cost, which may unjustifiably increase the federal award?s cost. Condition The award agreements require that the program expenses be reasonable and necessary and in compliance with federal regulations. The costs incurred by the College to run the projects of the COVID-19 Coronavirus Relief Fund and the FEMA Vaccination Grant violate the reasonability criteria established by the award agreements and the College procurement policies because it did not carefully document the justification of how the situation created an urgent need to perform the work sooner than a competitive process would allow. The selection of the vendors for supplies, equipment, materials, and services did not go through the College?s existing procurement requirements and the management did not provide adequate information to justify the selection of the vendors without a procurement process. Context The policies and procedures of the College establish clear guidelines of the procedures to follow in a procurement process. Effect Have an unjustifiably increase the federal award?s costs. Not having contracting provisions under an emergency scenario does not ensure accountability and transparency in the acquisition of supplies and services. Cause The management of the College outsourced the management of the federal programs and trusted in that personnel to carry out the activities of the programs in compliance with the College and federal programs regulations. However, the College did not designate a liaison to oversight and monitor the activities being carried out. Questioned costs $0. Recommendation We recommend the adherence of the College to the grant agreement and internal regulations and federal requirements. The management of federal funds demands prudence and sound business practices to avoid waste in the use of the funds. The management should revise the existing procurement policies and procedures to include contracting provisions under an emergency scenario ensuring accountability and transparency in the acquisition of supplies and services. Additionally, monitoring procedures must be established when internal activities are outsourced.

Identifying Number: 2021-003 Federal program: COVID-19 Coronavirus Relief Fund DS1075 FEMA Vaccination Grant DS1374 CFDA number: 21.019 & 97.036 Federal Agency: U.S. Department of Treasury and Homeland Security Passed through: Puerto Rico Department of Health Compliance requirement: Allowable Costs Identification as a Repeat Finding: Not a Repeat Finding Criteria The Coronavirus Relief Fund and FEMA Vaccination Grant were designed to provide ready funding to address unforeseen financial needs and risks created by the COVID-19 public health emergency. State, territorial, tribal, and eligible local governments are required to use payments from the awards to cover: 1. Necessary expenditures incurred due to the public health emergency with respect to the Coronavirus Disease 2019 (COVID?19); 2. Costs that were not accounted for in the most recently approved budget as of March 27, 2020; and 3. Costs that were incurred during the period that begins on March 1, 2020 and ends on December 31, 2021. The agreement with the pass-through entity also established that the awards should not be used for expenditures that the College already has. Condition The following conditions were identified: A. The College used the Coronavirus Relief Fund to pay itself rent income, utilities and phone expenses when the grant agreement did not provide for and did not allow this kind of activities. B. The FEMA Vaccination grant agreement allowed items for rent, utilities, and phone expenditures in the budget but when we examined the related expenditures, they were not properly supported with evidence of the expense amount. Context The Coronavirus Relief Fund did not have a budget for rent, utilities, and phone expenditures however, the pass-through entity approved $32,920 for project administrative costs under the grant agreement. The College reimbursed itself $46,800 for those concepts. The FEMA Vaccination Grant had a budget of $34,000 for facilities, communications, and utilities. The College reimbursed itself $76,460 and none of the expenditures have proper support, neither have a rationale of how the College determined that the amounts reimbursed are reasonable for the facilities used and if the facilities used were used for the FEMA Vaccination Grant. Effect Lack of proper support and justification of the expenditures incurred. Cause The personnel hired to manage the project lack of experience in managing federal programs and did not exercise due care in managing and reimbursement of administrative costs. Questioned costs ? $24,000 of rent and $22,800 of communication and utilities from the COVID-19 Coronavirus Relief Fund, for a total of $46,800 that were not properly supported. This is the total of 18 transactions recognized in the accounting books of which we examined 3 transactions where the management confirmed that the rest of the transactions were the same. ? $66,000 of rent and $10,460 of communication and utilities from the FEMA Vaccination Grant, for a total of $76,460. This is the total of 33 transactions recognized in the accounting books of which we examined 1 transaction where the management confirmed that the rest of transactions were the same. Recommendation The management must ensure the compliance personnel hired were adequately trained and had experience in the Uniform Guidance compliance requirements, grant agreements and in similar projects. The management must ensure that this personnel follows the College?s internal control and policies. Views of Responsible Officials and Planned Corrective Actions Management response is reported in the ?Corrective Action Plan? at the end of this report.

Identifying Number: 2021-004 Federal program: COVID-19 Coronavirus Relief Fund DS1075 FEMA Vaccination Grant DS1374 CFDA number: 21.019 & 97.036 Federal Agency: U.S. Department of Treasury and Homeland Security Passed through: Puerto Rico Department of Health Compliance requirement: Allowable Costs Identification as a Repeat Finding: Not a Repeat Finding Criteria Per Uniform Guidance section 200.403 Factors Affecting Allowability of Costs- a cost to be allowable needs to be adequately documented per the Uniform Guidance section criteria. Condition During the examination of several vendors expenditures, we found the following situations: A. Invoices that did not match the payments amounts. B. Invoices supporting expenditures that did not belong to the amount disbursed. C. Invoices without sufficient detail to determine that the cost was reasonable. D. Disbursements without invoices. Context We examined 25 transactions and found 8 without proper support from COVID-19 Coronavirus Relief Fund DS-1075. We examined 30 transactions from FEMA Vaccination Grant and found that 3 out 4 of reimbursements made to the same vendor were not properly supported. The total reimbursements made to this vendor amounted to $57,117. Effect Lack of proper support and justification of the expenditures incurred. Cause The College outsourced the management of the federal funds to an external company and even allowed this company to make purchases on behalf of the College without passing through the internal purchase process of the College. This resulted in override of the internal controls and policies of the College. Questioned costs ? COVID-19 Coronavirus Relief Fund-$48,658 without proper support of amounts. This is the total of 8 transactions. ? FEMA Vaccination Grant-$21,655 without proper support. This is the total of 3 transactions. Recommendation The College must establish and maintain effective internal control over the Federal award that provides reasonable assurance that has been managed in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. It must adequately safeguard all assets and assure that they are used solely for authorized purposes. Also, the management must ensure the personnel that is responsible for the oversight of the use of federal funds is adequately trained and have experience in the Uniform Guidance compliance requirements and grant agreements. Views of Responsible Officials and Planned Corrective Actions Management response is reported in the ?Corrective Action Plan? at the end of this report.

Identifying Number: 2021-005 Federal program: COVID-19 Coronavirus Relief Fund DS1075 FEMA Vaccination Grant DS1374 CFDA number: 21.019 & 97.036 Federal Agency: U.S. Department of Treasury and Homeland Security Passed through: Puerto Rico Department of Health Compliance requirement: Allowable Costs-Conflict of Interest Identification as a Repeat Finding: Not a Repeat Finding Criteria The College must use its own documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards established by section 200.318 of the Uniform Guidance, for the acquisition of property or services required under a Federal award. The College must maintain oversight to ensure that contractors perform in accordance with the terms, conditions, and specifications of their contracts or purchase orders. The College must maintain written standards of conduct covering conflicts of interest and governing the actions of its employees engaged in the selection, award and administration of contracts. No employee, officer, or agent may participate in the selection, award, or administration of a contract supported by a Federal award if he or she has a real or apparent conflict of interest. Such a conflict of interest would arise when the employee, officer, or agent, any member of his or her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has a financial or other interest in or a tangible personal benefit from a firm considered for a contract. The officers, employees, and agents of the non-Federal entity may neither solicit nor accept gratuities, favors, or anything of monetary value from contractors or parties to subcontracts. Condition In our examination of the expenditures of the COVID-19 Coronavirus Relief Fund and the FEMA Vaccination Grant we found the College granted two contracts for legal advisory related to the COVID-19 Coronavirus Relief Fund and the FEMA Vaccination Grant to an internal legal advisor of the College. Additionally, the College granted two contracts to an external company for the management, accounting, and reporting of COVID-19 Coronavirus Relief Fund and FEMA Vaccination Grant where the internal legal advisor is also the Treasurer of the external company, and her husband is the President of the external company. These legal advisory contracts denote a duplicity to the existing contract that the legal advisor has as internal legal advisor of the College and the contracts with the external company present a conflict of interest as defined and established by the Uniform Guidance section 200.318. Context The external company as registered in the State Department of Puerto Rico is engaged to foster medical education, educational and research services to medical professionals and did not appear to have apparent experience in the management of federal funds. Effect Use of her official position as agent of the College for private gain. Cause The College has well established policies of conflict of interest and procurement that it did not follow, therefore it is present an override of internal controls. There is finance and audit committee that does not perform oversight functions. Questioned costs ? COVID-19 Coronavirus Relief Fund- $38,861 for services provided during the 2021. ? FEMA Vaccination Grant- $222,460 for services provided during the 2021. Recommendation The Board of Directors must designate to the finance and audit committee a person with adequate qualifications in the accounting and audit areas to monitor the compliance of internal policies of the College and Federal regulations in order to bring situations like this to the attention of Board of Directors and its internal legal advisors on timely basis. Views of Responsible Officials and Planned Corrective Actions Management response is reported in the ?Corrective Action Plan? at the end of this report.

Identifying Number: 2021-006 Federal program: COVID-19 Coronavirus Relief Fund DS1075 FEMA Vaccination Grant DS1374 CFDA number: 21.019 & 97.036 Federal Agency: U.S. Department of Treasury and Homeland Security Passed through: Puerto Rico Department of Health Compliance requirement: Allowable Costs-Conflict of Interest Identification as a Repeat Finding: Not a Repeat Finding Criteria The College must use its own documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards established by section 200.318 of the Uniform Guidance, for the acquisition of property or services required under a Federal award. The College must maintain written standards of conduct covering conflicts of interest and governing the actions of its employees engaged in the selection, award and administration of contracts. No employee, officer, or agent may participate in the selection, award, or administration of a contract supported by a Federal award if he or she has a real or apparent conflict of interest. Conflict in fact occurs when the employee or volunteer of a grantee or subgrantee is responsible for decisions, approval, recommendations, disapproval concerning an organization in which they are serving as an officer, director, trustee, partner, or employee. Conflict in appearance occurs when an employee or a volunteer of a grantee or subgrantee takes actions that create the appearance that they are using their official position for private gain. Condition In our examination of the expenditures of the COVID-19 Coronavirus Relief Fund and the FEMA Vaccination Grant we noticed the College granted two contracts as program medical director to the President of the College in the amount of $18,000 and $60,000, respectively as of December 31, 2021. As established by the Uniform Guidance criteria and internal polices of the College these contracts were granted in a clear conflict of interest where an officer of the College is using its position for a private gain. Context The FEMA grant agreement with the Department of Health of Puerto Rico in the fifth article established that the funds must not be used to pay additional income to officers of the College including its president and vice-president. Effect Use of his official position as president of the College for private gain. Cause The College has well established policies of conflict of interest and procurement that it did not follow, therefore it is present an override of internal controls. There is finance and audit committee that does not perform oversight functions. Questioned costs ? COVID-19 Coronavirus Relief Fund-$18,000 paid from additional contract as medical director of the program. ? FEMA Vaccination Grant-$60,000 paid from additional contract as medical director of the program. Recommendation The Board of Directors must designate to the finance and audit committee a person with adequate qualifications in the accounting and audit areas to monitor the compliance of internal policies of the College and Federal Regulations in order to bring situations like this to the attention of Board of Directors and its internal legal advisors. Views of Responsible Officials and Planned Corrective Actions Management response is reported in the ?Corrective Action Plan? at the end of this report.

Identifying Number: 2021-007 Federal program: COVID-19 Coronavirus Relief Fund DS0947 & DS1075 FEMA Vaccination Grant DS1374 CFDA number: 21.019 & 97.036 Federal Agency: U.S. Department of Treasury and Homeland Security Passed through: Puerto Rico Department of Health Compliance requirement: Reporting Identification as a Repeat Finding: A Repeat Finding Criteria Per award agreement the College had to submit the following reports to the pass-through entity: ? Monthly financial reports with evidence of the breakdown of all program expenses incurred as of the date of the report before the 15th day following the month. The first report must be submitted (30) days after the date of signing of the Agreement. ? Monthly progress reports with evidence detailing the activities carried out during the period with the corresponding information that supports the work carried out, the population affected, the use of funds and possible problems that may be anticipated as of the date of the report before the 15th day following the month. The first report must be submitted (30) days after the date of signing of the Agreement. ? Comprehensive mid-point financial reconciliation report to be delivered on August 26, 2021. The report must detail the use of program funds as of the date of preparation, according to the approved budget and will include evidence of expenses incurred, payment vouchers or any other required documentation. ? Full final financial reconciliation report to be delivered on December 28, 2021. The report must detail the use of program funds according to the approved budget and will include evidence of expenses incurred, payment vouchers or any other required documentation. ? Final program closure report to be delivered on December 28, 2021. The report should include the activities carried out, funds used, population impacted by the program, including findings and recommendations. Condition The College did not provide evidence of submission of the reports described in the criteria section for the COVID-19 Coronavirus Relief Fund. The FEMA Vaccination Grant reports were submitted after the deadline. Context The management did not provide evidence of the reports submitted only the reports of the FEMA Vaccination Grant. Effect Non-compliance with reporting requirements of each mayor program. Cause The management indicated that once the reports are submitted, they cannot access the platform of the pass-through entity. Questioned costs $0. Recommendation Procedures should be established to ensure that financial reports are prepared and submitted on a timely basis and evidence of submissions should be saved to maintain record of the compliance. Views of Responsible Officials and Planned Corrective Actions Management response is reported in the ?Corrective Action Plan? at the end of this report.

Identifying Number: 2020-001 Federal program: COVID-19 Coronavirus Relief Fund CFDA number: 21.019 Federal Agency: U.S. Department of Treasury Passed through: Puerto Rico Department of Health Compliance requirement: Allowable Costs Criteria The award agreement requires that the program expenses be reasonable and necessary. A cost to be allowable needs to be reasonable. Per Uniform Guidance section 200.404 a cost is reasonable if, in its nature and amount, it does not exceed that which would be incurred by a prudent person under the circumstances prevailing at the time the decision was made to incur the cost. In determining reasonableness of a given cost, consideration must be given to among other requirements (a) The restraints or requirements imposed by such factors as: sound business practices; arm?s-length bargaining; Federal, state and other laws and regulations; and terms and conditions of the Federal award (b) Market prices for comparable goods or services for the geographic area (c) Whether the individuals concerned acted with prudence in the circumstances considering their responsibilities to the non-Federal entity, its employees, the public at large, and the Federal government (d) Whether the non-Federal entity significantly deviates from its established practices and policies regarding the incurrence of cost, which may unjustifiably increase the federal award?s cost. Condition The award agreement requires that the program expenses be reasonable and necessary and in compliance with federal regulations. The costs incurred by the College to establish the telemedicine platform such as project set-up and course design and advertising services violates the reasonability criteria established by the award agreement and the College procurement policies because did not carefully document the justification of how the situation created an urgent need to perform the work sooner than a competitive process would allow. The following conditions were identified: ? The selection of the vendors for project set-up, course design, LMS platform and marketing and advertising services did not go through the College?s existing procurement requirements and the management did not provide with adequate information to justify the selection of the vendors without a procurement process. ? Additionally, the contracts were awarded for the exact amount of the grant budget without exploring savings options. Context The notice of award was approved on October 15, 2020, and the grant agreement original expiration date was December 31, 2020 which later was extended to December 31, 2021. As of December 31, 2020, a total cost of $320,100 allocated among 3 vendors, was incurred to establish the telemedicine platform, project set-up and course design and advertising services. Cause The management of the College indicated that due to the short amount of time they had to deploy the funds, they did not have the time to enter into the documentation of the justification to forgo the procurement process or enter into a procurement process. Questioned costs $0. Recommendation We recommend the adherence of the College to the grant agreement and internal regulations and federal requirements, for the remaining use of the funds. The management of federal funds demands prudence and sound business practices to avoid waste in the use of the funds. The management should revise the existing procurement policies and procedures to include contracting provisions under an emergency scenario ensuring accountability and transparency in the acquisition of supplies and services. Views of responsible officials and corrective actions Management response is reported in the ?Corrective Action Plan? at the end of this report.

Identifying Number: 2020-002 Federal program: COVID-19 Coronavirus Relief Fund CFDA number: 21.019 Federal Agency: U.S. Department of Treasury Passed through: Puerto Rico Department of Health Compliance requirement: Reporting Criteria Management is responsible for preparation of the schedule of expenditures of federal awards (SEFA) in accordance with the Uniform Guidance. Condition Management did not prepare the schedule of expenditures of federal awards. Context This is the first time the College has federal awards, although they hired a company to assist them in the compliance process. Cause The finding was a result of the lack of awareness of management of the requirements related to reporting expenditures in the SEFA. Questioned costs $0. Recommendation The management must ensure the personnel is adequately trained in the requirements of the Uniform Guidance in order to provide the adequate reports for the compliance of the requirements of the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions Management response is reported in the ?Corrective Action Plan? at the end of this report.

Identifying Number: 2020-003 Federal program: COVID-19 Coronavirus Relief Fund CFDA number: 21.019 Federal Agency: U.S. Department of Treasury Passed through: Puerto Rico Department of Health Compliance requirement: Reporting Criteria Per award agreement the College had to submit the following reports to the pass-through entity: ? Monthly financial reports with evidence of the breakdown of all program expenses incurred as of the date of the report before the 15th day following the month. The first report must be submitted (30) days after the date of signing of the Agreement. ? Monthly progress reports with evidence detailing the activities carried out during the period with the corresponding information that supports the work carried out, the population affected, the use of funds and possible problems that may be anticipated as of the date of the report before the 15th day following the month. The first report must be submitted (30) days after the date of signing of the Agreement. ? Comprehensive mid-point financial reconciliation report to be delivered on February 26, 2021. The report must detail the use of program funds as of the date of preparation, according to the approved budget and will include evidence of expenses incurred, payment vouchers or any other required documentation. Condition The College did not submit the monthly financial and progress reports on time and the mid-point report has not been submitted. Context Based on inquiries made to management, we found that the late submitted reports were submitted late because access problems to the platform of the pass-through entity. The mid-point report has not been submitted. Cause The management indicated they had access problems to the platform of the pass-through entity. The mid-point report has not been submitted because they understood the report was extended with third amendment to the agreement. Questioned costs $0. Recommendation Procedures should be established to ensure that financial reports are prepared and submitted on a timely basis. Views of Responsible Officials and Planned Corrective Actions Management response is reported in the ?Corrective Action Plan? at the end of this report.