«CALL TO ORDER Ms. Emily A. Youssouf Adoption of Minutes December 4, 2014 Ms. Emily A. Youssouf • INFORMATION ITEMS Audits Update Mr. Chris A. ...»
Mr. Bukzin moved on to page nine, Vendor Listings – this is a new audit procedure that we did just to basically compare who was on the vendor master listing file to a listing of active employees, and we did identify some employees that were on the vendor master file. Our recommendation is for management to enhance controls of policies and procedures to ensure that when someone is hired that they are removed from that vendor master list on file. On page ten, Account Analysis Received from Other Departments, this is actually the subset from what we detailed when we presented the results of the financial statements. We only highlight a number of post-closing adjustments, one is related to the double accounting of an accrual for asbestos, pollution remediation liability. Then there was also a cut-off issue related to pool rather than for net patient services by account $100 million. This comment gets to the point of making sure there is a default review of analysis received from other departments that falls into the lap of the finance team. Page eleven has one of our IT-related findings around timely removal of terminated users. There were two findings under the subcategory related to access perhaps after the employee was no longer employed by the organization. There should be tightened controls and processes between HR and IT process to make sure that the removal of employee occurs on a timely basis.
Mr. Bukzin continued with page twelve stating that it covers some of the site-visit findings or findings relevant to a specific entity. The first one relates to a finding at the Coney Island Hospital where there was a fixed asset that was marked as received and accrued for when in fact the facility did not have possession of it. This was somewhat of an isolated instance around Super Storm Sandy, and they did actually have possession of it, but the vendor took it back for safeguarding and safekeeping during the process. Ongoing communications enhancing policies and procedures around vendor payment and when assets are returned or perhaps not been received yet. Bottom of page twelve, Goldwater Movable Equipment Disposal – not material to the financial statements, but there were some assets that were transferred as part of that closure transaction that were not accounted for. This is an opportunity for enhancing policies and procedures and communication in that area.
Mr. Bukzin stated that page fourteen covers the prior-year comments that were addressed by management. These are comments that appeared in last year’s management letter that were considered remediated or addressed by management. The first one falls under the heading Construction Management. There were several observations around construction progress, monitoring budgets, over-runs, making sure that items that are construction in progress (CIP) are properly accounted for and captured in a general ledger system. Management has gone through a process of implementing tools to track it. They mentioned a Scorecard Tool, which helps to identify scope issues and if there is going to be over-runs issues with the initial budget that was established for that project and they did provide to us to review as part of the remediation of this comment.
Mr. Bukzin continued with page fifteen, Material Management and stated that again, there were a handful of observations related to segregation of duties, related to receiving, paying and ordering goods. Management has implemented and adopted new procedures to ensure that there is segregation of duty between receiving and payments, approval process, and also the Office of Internal Audits plans to do a more detailed review of this area in connection with the centralized procurement function. The other observation relates to cut off of expenses and reporting of grants. We did not identify any similar issues related to that area in the current year, and management has offered a process of training its employees, making sure there is a verification review process in place to ensure those expenses are reported in the proper period in accordance with the grant management. On page seventeen, there are some prior-year site-visit findings around payroll and material management. These policies and procedures have been adopted and enhanced and we did not have any similar findings in the current year related to these.
Mr. Bukzin asked if there were any further comments at that point. He turned the presentation over to Ms. Tiso.
Ms. Tiso continued with page nineteen through thirty-one and stated that these are industry comments. These comments are specifically included in HHC’s letter as information only and we do not include them in other health organizations. The first is Internal Audit Reporting – the best practice is that the Chief Internal Auditor should report to the Chief Executive Officer or the Chief Financial Officer. He currently reports to the Chief Operating Officer, so best practice is to change the reporting structure. The organization is currently looking into that. Page nineteen also talks about the DISRIP Program and page twenty talks about Convergence in Healthcare. To me they are similar comments, right now healthcare is transforming, the organization needs to merge and affiliate with other organizations and converge going forward.
Mrs. Bolus asked if DISRIP pays for any IT systems? To which Ms. Zurack responded that DISRIP does not pay capital. However, New York State in tandem with DSRIP has appropriated $1.2 billion for capital, but it is possible there could be some IT. That application is going kind of parallel to DSRIP and it is due the third week of February.
Mr. Martin added that yes, but that $1.2 billion is over a seven-year period. Ms. Zurack commented that that is for the whole State.
Ms. Tiso moved on to page twenty-four which talks about the ICD-10 extensions approved by the Senate. Obviously, the ICD-10 diagnostic and procedure codes need to be implemented over the next several years. The effective date was supposed to be October 1, 2014, but that has been extended. Our comment here is just to make sure that the organization is currently on track to implement the ICD-10 when the date gets approved. Page twenty-four and twentyfive and the top of page 26 talk about HIPAA compliance. There is a lot of discussion about protecting patient health information and making sure that your corporate compliance program addresses that, looking at subcontractor agreements and vendor agreements, making sure that those parties are also protecting the patient information. I know that HHC does a good job with that because KPMG gets forms to complete. Page 26 talks about data analytics – this is top-of-mind on all governance committee meetings now. A lot of people do not understand how to use them at this point, but going forward, this really needs to be looked at by the organization to figure out how to decrease expenses and increase quality. Page twenty-seven is social media. Our comment is to make sure that the organization has a plan in place to address any social media risk. Page 28, Use of Cloud Computing in Healthcare – healthcare in general is lagging behind on the use of cloud computing. Our comment is that healthcare organizations could really reduce costs as it relates to data storage. Page 29 talks about Oversight – there is a lot of oversight, the SEC obviously is involved in not only public companies but also government entities, bond offerings, municipal examinations. This comment is about the fact that the SEC is not only monitoring public accounts but also private and governmental accounts as well. Page thirty, the Sunshine Act, CMS requires any manufacturing or group purchasing organizations to have a list of any physicians that gets any type of payments or gifts. There needs to be a listing and Corporate Compliance probably needs to make sure physicians, or they are looking at conflict-of-interest statements, making sure those are completed accurately, making sure there are no surprises from the Corporation’s perspective.
Mr. Page asked in terms of this latter section of the letter, is this something generic to your healthcare clients? Ms.
Tiso responded yes.
Mr. Page then asked if they include this section in your management letters to all of your audit healthcare clients. Ms.
Tiso answered yes, we typically do. Our management letters are broken out into the actual facility observations and the industry. The reason we do that is because the management letter is supposed to go to your governing body, and it is to keep them aware of what is going on.
Mr. Page then commented that it seems off as a vehicle because it strikes me as quite different in its substance from your client-specific comments. I am surprised that it is in the management letter, it is valuable and it is good that you give it to us.
Ms. Tiso added that historically it has been; we have had one-offs where the organization does not want it and we will issue a separate letter. It depends upon what you like. I prefer to put it in there, it gives everybody one place to look at the comments.
Ms. Zurack added that in other years you have told us how we are doing relative to others on some of those areas and it is helpful.
Mrs. Bolus asked for a motion to approve the management letter, it was seconded and approved by the Committee.
Mrs. Bolus said thank you very much, very complete and we will follow-up. Mrs. Bolus then moved on to the next item on the agenda, Mr. Telano.
Mr. Telano saluted everyone and stated that page three of the briefing summarizes the status of the audits being conducted by government agencies. The first one is the audit of the Lincoln Affiliation Agreement conducted by the New York City Comptroller’s Office. It began last July 2013, and it is still ongoing. They are currently conducting interviews and obtaining information from the PAGNY side of the audit. The second audit is related to the Patient Revenue and Accounts Receivable. At this point in time they are attempting to request information that we consider protected health information, Mr. Russo and Mr. McNulty have been involved in the discussions with them because we do not want to provide this confidential information. This is an ongoing matter and we will keep you updated. On page four is the Bellevue Hospital’s Emergency Operations Plan. The City Comptroller’s Office has decided to close that audit at this time, but they reserve the right to reopen it at a later date. The next audit listed is one being done by the State Comptroller’s Office, a follow-up of overtime and that is ongoing. We have sent them additional information this week and we hope to receive some status of the findings shortly.
Mr. Telano continued on with page five which lists the audits that the Office of Internal Audits has completed since the last meeting. Coincidentally, all of the audits for this meeting are of the South Manhattan Network. The first audit is of Hospital Police at Bellevue. Mr. Telano asked the representatives to approach the table and introduce themselves.
They did as follows: Joseph Sweeney, Director of Hospital Police at Bellevue; Kirk Leon, Director of Corporate Security; Mr. Steven Alexander, Executive Director of Bellevue.
Mr. Telano stated that during the course of the audit, we evaluated the payroll and use of resources. We noted that security posts were not always regularly manned. On two specific dates, we found that 6 of the 27 posts were vacant.
We also noted that extensive amounts of overtime were being earned by the Hospital Police, and additionally we found that the Bellevue Police was borrowing personnel from other sites and this expense was not always charged back.
Mr. Sweeney said that we have some posts assignments that are mandatory 24 hours a day, 7 days a week; there is no reason that the person assigned to that post should leave the post. However, we have many posts that may be covered all day except when that person is called to an emergency situation and some are left for meal or breaks. The people on the post are responsible to escort somebody out of the building or to our CPEP. There are variety of reasons why somebody might not be on the post that they assigned to.
Mr. Alexander added that on some posts there might be two people assigned, and that would be considered two posts for two individuals, so one person who had to respond to an emergency did not leave that particular post totally uncovered. It was basically reduced from two one person on that site at that time.
Mrs. Bolus asked how often you actually walk through the actual stations.
Mr. Sweeney responded not as often as I probably should. We do rounds maybe once every two weeks or so, but I will visit each post in the different course of my business a couple times a week.
Mrs. Bolus asked if there is any way that they may know what your schedule is. To which Mr. Sweeney responded no.
I have many other supervisors that their job is to randomly go to these posts and the uniformed supervisors are mandated to go to the post at least twice a shift and they are supposed to sign their books, so we have a process to make sure that these folks are on the posts.
Mr. Martin added that we need to make a differentiation between the mandatory posts and the sort of posts that are good to have. Twenty-seven is a tremendous amount of posts to have any facility. They are operating at an overabundance of caution when they have 27 posts. I want the Board to feel comfortable that the mandatory posts, the ones that really protect the security of the facility are being manned on a consistent basis.
Mr. Page added that obviously the underlying point is you hope that the personnel you are paying for to man the posts are actually doing that as opposed to doing something else.
Mr. Sweeney stated that that is the concern, but I can assure you that it is busy enough that everybody is doing something at one point or another. I am confident that nobody is disappearing from the post and sleeping somewhere or off somewhere doing something they are not supposed to. If they are off the post, it is for a specific reason and we are on top of it.
Mr. Telano then asked about the overtime and the use of personnel from other facilities?