Corrective Action Plan Quarterly Update Guidance

Purpose

This guidance explains expectations for submitting quarterly updates on open Corrective Action Plan (CAP) items until corrective actions are completed, verified, or otherwise resolved.

Quarterly updates show what progress has been made, what remains outstanding, whether target dates have changed, and what documentation supports completed or partially completed work.

The quarterly update should be read with the final audit report and the approved CAP. It should clearly connect each progress update to the related audit recommendation and CAP item.

Why Quarterly CAP Updates Matter

Quarterly CAP updates help the university:

Track progress toward resolving audit recommendations.
Provide leadership and the Board of Visitors Audit Committee with reliable information about outstanding audit issues.
Support future follow-up audits by showing what was done and what documentation supports completion.

A strong quarterly update helps everyone understand what has been done, what remains to be done, whether the target date has changed, and what supporting documentation shows progress or completion.

Providing Quarterly CAP Updates

This section explains what department should include in each quarterly update for open CAP items.

At a Glance: Quarterly Update Submission

Current status for each open CAP item.
Progress made during the quarter.
Revised completion date, if needed.
Explanation for delays, barriers, or changes in approach.
Supporting documentation for completed or partially completed work.

Expectations for Quarterly CAP Updates

Quarterly updates help Internal Audit monitor progress, identify delays, and report the status of outstanding corrective actions to leadership.

Quarterly updates should be timely, complete, and specific. Each update should describe progress made during the quarter rather than repeat prior language.

For each open CAP item, the quarterly update should include:

A dated description of progress.
Any new or revised supporting documentation.
An updated status.
Any revised completion date, if applicable.
An explanation for delays, barriers, or changes in approach.
Any assistance, clarification, or coordination needed from Internal Audit or other offices.

If no progress was made during the quarter, the update should state that no progress was made and explain why. This is preferable to leaving the item blank or repeating a prior update without explanation.

If an item is partially completed, the update should describe what has been completed, what remains to be done, and the expected timing for the remaining work.

If ownership changes, the update should identify the new responsible party and briefly explain the reason for the change.

Quarterly Update Schedule

Internal Audit sends a reminder and template before each quarter-end. Departments should submit CAP updates by the due dates below. Internal Audit generally reports CAP status by the end of the month following quarter-end.

Quarter End	Template and/or Reminder Email Template Sent	CAP Updates Due	Internal Audit Reporting Target
March 31	March 15–20	April 15	April 30
June 30	June 15–20	July 15	July 31
September 30	September 15–20	October 15	October 31
December 31	December 10–15	January 20	January 31

After each deadline, Internal Audit reviews updates and supporting documentation, sends follow-up questions as needed, and may follow up with department management on overdue or incomplete updates.

Description of Progress

Provide a clear description of what has been done since the CAP was submitted or since the last quarterly update. Each update should include a date.

A useful progress update should answer:

What specific work has been completed?
What remains to be done?
What documentation has been created, updated, approved, or uploaded?
What decisions have been made?
What obstacles, delays, or dependencies exist?
Has the target date changed? If so, why?
Is Internal Audit review or clarification needed?

Progress updates should be specific and supported by documentation. Statements such as “in progress,” “ongoing,” or “completed” are not sufficient by themselves.

Revised Completion Date, if Needed

If the original target date changes, provide a revised completion date and explain the reason for the change. Revised dates should be based on actual circumstances, not simply moved forward each quarter without explanation.

Examples of reasons for revising a completion date may include a dependency on another system, project, or department; staffing changes; a change in university priorities or available resources; a need for additional review; or a decision to phase implementation.

Current Status

Select the current status that best reflects the actual progress made. The status should align with the description of progress and supporting documentation.

Not Started: Work has not yet begun.
In Progress: Work has begun but is not complete.
Completed: The department has finished the corrective action and believes it is ready for Internal Audit review.
Other: The item needs a different status or additional explanation.

Supporting Documentation

Provide documentation that supports the work completed and shows how the corrective action addresses the recommendation. Supporting documentation should be uploaded to the SharePoint CAP file.

Documentation should be clearly labeled and tied to the related observation or CAP item. If one document supports multiple CAP items, identify which items it supports.

Departments should retain CAP-related documentation according to applicable university and records retention requirements.

Examples of Quarterly Updates

A strong quarterly update is clear, factual, and specific. It should help someone outside the department understand what changed during the quarter.

Example 1: Vague Progress Update

“Procedures are being updated.”

Stronger Version

“As of March 31, 2026, the department drafted revised cash handling procedures and routed them to Finance for review. The draft procedures include updated approval steps, documentation requirements, and annual training expectations. Finance feedback is expected by April 15, 2026. The target completion date remains June 30, 2026.”

Example 2: Unsupported Completion Update

“Completed.”

Stronger Version

“As of June 30, 2026, the revised procedure was approved by the department director and Finance, posted to the department SharePoint site, and communicated to staff by email. Training was completed on June 20, 2026, and the attendance record has been uploaded. The department considers this item complete and ready for Internal Audit review.”

Using “Completed” Status

A CAP item should be marked “Completed” only when the department has finished the corrective action and can provide supporting documentation showing that the action was implemented.

Before marking an item completed, consider whether:

The corrective action fully addresses the recommendation.
The new or revised process has been approved, if approval is required.
Staff have been informed or trained, if applicable.
Required forms, templates, procedures, or system changes are in use.
Supporting documentation has been uploaded or provided.
The action is sustainable beyond a one-time fix.

Internal Audit may keep a completed item pending verification until documentation has been reviewed or follow-up testing confirms that the corrective action meets the intent of the recommendation.

After Internal Audit verifies completion, the item will be considered closed and will no longer require quarterly updates.

Common Quarterly Update Issues to Avoid

To help prevent delays, departments should avoid these common quarterly update issues:

Repeating the same update each quarter without new information.
Marking items completed without supporting documentation.
Uploading documentation without identifying which CAP item it supports.
Omitting dates from progress updates.
Waiting until the quarterly deadline to raise barriers or dependencies.

Internal Audit Review and Follow-Up

Internal Audit reviews quarterly updates for clarity, completeness, supporting documentation, and alignment with the related audit recommendation and CAP item. Internal Audit may request clarification, additional documentation, or revisions when needed.

After the department marks an item completed, Internal Audit may perform follow-up review or testing. The purpose of follow-up is to determine whether the corrective action meets the intent of the recommendation and whether the related control or process is in place and functioning as intended.

Roles and Responsibilities

Department Management

Department management is responsible for:

Providing quarterly updates.
Uploading or providing supporting documentation.
Communicating delays, barriers, or changes in approach.

Responsible Party

The responsible party is responsible for:

Coordinating completion of the corrective action.
Gathering input from supporting offices or staff.
Tracking progress and keeping the action on track.
Providing accurate quarterly updates.
Ensuring supporting documentation is retained and provided to Internal Audit.
Notifying management and Internal Audit if barriers arise.

Internal Audit

Internal Audit is responsible for:

Providing the quarterly update template and related guidance.
Answering questions about quarterly update expectations and supporting documentation.
Reviewing quarterly updates and related supporting documentation.
Monitoring progress toward completion.
Requesting clarification or documentation when needed.
Reporting CAP status to leadership, as appropriate.
Performing follow-up review or testing when corrective actions are marked completed.

Quarterly Update Checklist

Use this checklist before submitting each quarterly update:

Each open item includes a current progress update.
Progress updates describe what changed during the quarter.
Updates include dates.
The current status matches the actual progress made.
Revised completion dates are explained.
Supporting documentation has been uploaded or provided.
Documentation is labeled or described so Internal Audit can match it to the correct CAP item.
Completed items include documentation that supports Internal Audit review.
Items with no progress include a brief explanation.
Barriers, dependencies, or requests for clarification are clearly identified.

Final Reminders

Quarterly CAP updates work best when they are clear, timely, and supported by documentation. A clear update helps everyone understand the current status, what has changed, what still needs to be done, and whether the item is ready for Internal Audit review.

Departments should contact Internal Audit early if they have questions about the quarterly update, current status, revised completion date, barriers, or supporting documentation.