Activity

Impact

Completed compliance progress reviews in the areas of fire safety, laboratory security, wastewater regulations, health information management, Emergency Medical Treatment and Active Labor Act, and hospital billing.

The Institutional Compliance Program (ICP) was provided an assessment of the soundness of the methodologies used to monitor and to develop status and monitoring reports for these compliance areas.  Additionally, an assessment was made regarding the accuracy of the status and monitoring reports provided to the ICP by these compliance risk areas.

Health Information in Mission Critical Systems Planning Project

The purpose of this project was to gain a general awareness of the environment in which health information resides and to identify the associated risks/potential issues.  The information obtained during this project was used as an input into the Audit Services FY 2002 institutional risk assessment and work plan develop process.

UT System Cost Savings Initiatives Validation Project

Staff participated in this bi-annual process through informal and formal reviews of reasonableness of projected savings associated with proposed new cost saving initiatives as well as the reported results of previously adopted initiatives. 

Faculty Practice Facilitated Self-Assessment

The purpose of this project was to facilitate management’s efforts to identify the perceived strengths, weaknesses, opportunities, threats, and challenges facing the Faculty Practice. 

Follow-up procedures performed for 52 previously identified audit issues. 

Institutional management was provided an update on the current status of outstanding audit issues.  It was determined that 91% of these issues were either fully (81%) or partially (10%) resolved.

Institutional Risk Assessment and Work Plan Development Project

The objective of this project was the development of an Audit Services work plan for FY 2002 that is aligned with the institution’s goals and objectives and the significant risks to their achievement.  A substantial part of the foundation of this work plan is the considerable input received from executive and operational management into its development.

Department of Biomedical Engineering

and Electronics Inventory Review

Beginning in fiscal year 2002 the responsibility for the BMEE service department will transfer from the Vice President for Business Affairs to the Vice President for Research.  Audit Services was asked to assist BMEE in their goal of providing an accurate actual year-end inventory to the new management.  Toward this end Audit Services provided feedback on the physical inventory methodology, performed test counts of the physical inventory and reviewed the compilation and adjustments of the final inventory for accuracy and support. 

Facilitated Assessment – Clinical Research

The Office of the Vice President for Research, in its continuing efforts related to clinical research compliance, established a team to develop a method for assessing legal risks to the institution resulting from the conduct of human subject studies.  That team invited Audit Services to work with them in an effort to ensure sound and comprehensive development of the methodology.  Audit Services met with the team on two occasions to provide input and facilitate discussion of the topics.

Health Insurance Portability and Accountability Act (HIPAA)

Audit Services currently holds a membership on the HIPAA Steering Committee Task Force.  The task force currently assists the Institutional HIPAA Project manager, the Institutional Compliance Program, with guidance, acceptance, and communications of HIPAA to the UTMB campus.

IT Standards and Training

The goal of the Information Security Policy and Practice Standards Taskforce is to identify and prioritize IT-specific security risks that exist in the UTMB IT environment.  The realistic control of the IT systems on the UTMB campus remains a key issue to enhancing the overall security of all items relating to the computer network.  A consensus feeling of fair, strong and enforceable IT system policies will help the Information System (IS) staff gain a greater amount of network control while reducing the amount of IT risks that UTMB deals with on an ongoing basis.  Audit Services has been participating on the Security Policy and Practice Standards Taskforce. 

Business Systems Replacement and eCommerce

In Fiscal Year 2001, the Chief Financial Officer and the Vice President for Business Affairs requested Audit Services participation in the PeopleSoft Project.

Audit Services involvement in the project was to ensure that proper controls were included in the new business processes.  To accommodate this request, Audit Services budgeted 800 hours to address operational, financial, compliance, and information technology issues. These 800 hours were represented on the Audit Services FY 2001 Work Plan as two separate projects, eCommerce and Business Systems Replacement.  Both projects were merged to what we now refer to as the PeopleSoft project. 

The contract for PeopleSoft was finalized late during FY2001.  During the 4^th quarter, a Gap/Fit Analysis was performed to determine the current state of UTMB.  The result from this analysis is currently being used to develop an implementation timeline by the end of September 2001.  Once a timeline is completed, the project team and Audit Services will work together to determine the best use of our time for Fiscal Year 2002.  Our current involvement has been a member on the Horizon Advisory Task Force. 

Review of Executive Travel

Our limited-scope review covered travel from September 1999 – July 2000.  We conducted detailed testing on travel vouchers for executive travelers (Executive Vice President, Vice Presidents, Deans, and Chief Financial Officer) that exceeded $500.  Travel of the President was not included in this review as it was examined by the Chief Financial Officer.  We tested all instances of potential reimbursement for the executives’ spousal travel.  We also conducted detailed testing on transactions for any traveler whose voucher exceeded $5,000.  The results of our review were shared with executive management.

Overall, the review revealed that costs incurred by executives were adequately supported and in compliance with University and State Travel Guidelines.  Our executive travelers spent an average of $3,383 per person on travel for the year.  Several recommendations were made to management regarding the results of our testing of the other non-executive high-dollar travel vouchers.

Review of Continuing Medical Education

The Office of Community Outreach requested that Audit Services conduct a review of the continuing education process, in light of recent management changes in that area.  We worked with staff from the Office of Continuing Education (OCE) to review their business support processes, excluding the Physician’s Relations Program and program effectiveness issues.  There were a number of areas identified where management could improve their processes, including more comprehensive computer software, controls over cash receipts and disbursements, and contracting with sponsoring departments and commercial supporters. 

Review of LASIK Eye Center Financial Accounts

Executive management requested a special review of financial results and information related to its Clear Lake LASIK Eye Center.  The comprehensive review included information on financial performance, reporting of information to management, potential conflicts of interest, and observations on the general business environment.