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DALLAS COUNTY HOSPITAL DISTRICT PARKLAND HEALTH

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					DALLAS COUNTY HOSPITAL DISTRICT
PARKLAND HEALTH & HOSPITAL SYSTEM


INTERNAL AUDIT SERVICES




DATE:    October 13, 2010


TO:      Audit & Compliance Committee
         PHHS Board of Managers


FROM:    Vic Summers, Senior Vice President
         Internal Audit Services


RE:      Health Insurance Portability and Accountability Act (HIPAA) Monitoring,
         Fiscal Year 2010 – 3rd & 4th Quarters, Report No. 2010-501


         Attached please find our final third and fourth quarters report on HIPAA Monitoring.


         Regards.




         Attachments

CC:      Ron J. Anderson, M.D., President & Chief Executive Officer
         John Dragovits, Executive Vice President & Chief Financial Officer
         John Haupert, Executive Vice President & Chief Operating Officer
         Jack Kowitt, Senior Vice President & Chief Information Officer
         Vicki Crane, Senior Vice President, Clinical Support
         Sharon Philips, Senior Vice President, Community Medicine
         Brad Simmons, Senior Vice President, Surgical Services
         Nancy Merritt, Vice President & Compliance Officer
         Richard Rhine, Vice President, Revenue Cycle
         Nancy Folz-Murphy, Deputy Chief Information Officer
         Kenya Woodruff, Deputy General Counsel
         Geoffrey Camp, Director of Radiology
         James Carpenter, Director, Information Technology & Security
         Cathy Haliburton, Director of Privacy/Privacy Officer, Corporate Compliance
         Bob Reed, Director of Patient Access
         Suzanne Sims, Director of Ambulatory Services
 DALLAS COUNTY HOSPITAL DISTRICT
 PARKLAND HEALTH & HOSPITAL SYSTEM


 INTERNAL AUDIT SERVICES
 HIPAA Monitoring, Fiscal Year 2010 – 3th & 4th Quarters, Report No. 2010-501




1. Misdirected Faxes
         Per Parkland’s HIPAA Administrative Guidelines on Breach reporting, HIPAA Privacy Standards 45
EXPECTED C.F.R. §164.502(b), §164.514(d), and the Information Security policy prevent further disclosure of the
CONTROLS breach of patient privacy by contacting the recipient of the misdirected fax and request that the entire
         content of the misdirected fax be destroyed. The Parkland Privacy office should be notified through
         email or phone of these incidents.

 STATUS

2. Notice of Privacy Practices

EXPECTED Per HIPAA Privacy Standards 45 C.F.R. § 164.520(a), all patient medical records should include a
CONTROLS signed Acknowledgment Form showing receipt of the Privacy Notice or documenting the patient’s
         decision to decline or refuse.

 STATUS

3. High Profile Patients
EXPECTED
CONTROLS Parkland’s high profile patient’s identity should be protected and maintained.

 STATUS

4. Point of Disclosure - Breast Imaging
         Parkland’s Release of Information process is intended to safeguard patients’ confidential health care
EXPECTED information by setting guidelines for the release of patient medical information. A valid written and
CONTROLS signed disclosure authorization should be completed as per HIPAA’s Privacy Standards 45 C.F.R. §
         164.508(c).

 STATUS

5. Breach Notification for Unsecured PHI
         Under the HITECH Act § 13402, a covered entity that discloses unsecured PHI is required to notify each
         potentially affected individual of any breach where the information may have been released. Unsecured
EXPECTED
         information means information not protected through technology or methods designated by the federal
CONTROLS
         government. In addition, if the breach involves 500 or more individuals, notice to the Federal
         Department of Health and Human Services and the media is also required HITECH §13402(e)(4).

 STATUS

 6. Accounting of Disclosures
            Parkland’s HIPAA Administrative Guidelines states that individuals can request an accounting of certain
            non-routine disclosures of protected health information including public health and other public
EXPECTED purposes. The HITECH Act requires New Accounting Rules to be effective as an Electronic Health
CONTROLS Record is set up. The New Accounting rules add business associates to report their PHI disclosures if
            requested. They must provide a list of all their associates and their disclosures. 45 C.F.R.
            §164.528(a).

 STATUS

                                                     A-2
DALLAS COUNTY HOSPITAL DISTRICT
PARKLAND HEALTH & HOSPITAL SYSTEM


INTERNAL AUDIT SERVICES
HIPAA Monitoring, Fiscal Year 2010 – 3th & 4th Quarters, Report No. 2010-501

                                           Executive Summary

Background:

Compliance with the Health Insurance Portability and Accountability Act (HIPAA), specifically Privacy and
Security standards, ensures that the use of Protected Health Information (PHI) is consistent with Federal
and State law. Parkland Health & Hospital System’s (Parkland) daily practice should reflect safeguards
and protections intended to eliminate inappropriate use or disclosure of patient information. The American
Recovery and Reinvestment Act of 2009 (ARRA) has new HIPAA provisions, most of which went into
effect on February 18, 2010. ARRA included a Health Information Technology for Economic and Clinical
Health Act (HITECH). Internal Audit Services (IAS) continues to assess Parkland’s compliance with
HIPAA standards by performing quarterly monitoring audits in conjunction with the Privacy and Security
Offices.

The objectives of this review were to determine if Parkland has processes in place that continuously
safeguard PHI. To accomplish this objective, Internal Audit Services performed the following:

1. Documented a bench-line for how Parkland employees respond to misdirected faxes.
2. Tested 25 first-time patients, as well as those that came into the emergency department coded as
   unresponsive and/or trauma between January and March 2010 to verify a Privacy Notice and
   Acknowledgment Form was completed.
3. Identified high profile patients and verified that identities are being treated appropriately.
4. Continued to look for areas that may be releasing PHI without the proper forms.
5. Reviewed that Parkland has processes or procedures for reporting of unsecured protected health
   information.
6. Requested a log of Accounting Disclosures to review for Compliance with HIPAA Privacy Standards.

Conclusion:

Overall, Parkland has internal controls in place to aid in the compliance with the Health Insurance
Portability and Accountability Act of 1996 Privacy Rule and is working to implement processes to comply
with the new changes from HITECH.

Internal Audit Services has identified opportunities to improve Parkland’s compliance with HIPAA Privacy
Rule specifically addressing specific observations, as well as controls reviewed during the quarter, are
summarized below:

1. Misdirected Faxes: IAS randomly contacted 10 areas and presented employees answering the
   phone with a mock situation where an individual outside of Parkland received a fax with patient
   information. The caller asked for guidance on what should be done with the misdirected patient
   information to see what types of answers would be presented.

    Ten of 10 (100%) areas did not request identifying information from the caller to report the issue to
    the Privacy Officer.

    Employees made various suggestions that ranged from destroying the fax to faxing the document
    back to the department.

    IAS met with Information Security to discuss the expectations of employees when they are notified of
    a misdirected fax. Information Security is currently reviewing best practices and documenting a
    process that instructs employees on what is expected when they are notified of a misdirected fax.

        Management Response: Jack Kowitt, Senior Vice President & Chief Information Officer
        Information Security is working with Internal Audit to create guidance for transmission of faxes.
        Targeted Completion Date: November 30, 2010


                                                    A-3
DALLAS COUNTY HOSPITAL DISTRICT
PARKLAND HEALTH & HOSPITAL SYSTEM


INTERNAL AUDIT SERVICES
HIPAA Monitoring, Fiscal Year 2010 – 3th & 4th Quarters, Report No. 2010-501

        Management Response: Nancy Merritt, Vice President & Compliance Officer
        We will continue to support the Security Officer's education and training programs for handling
        ePHI by reinforcing his efforts through our privacy training for all employees.

 2. Notice of Privacy Practices: Internal Audit randomly selected 20 first time Parkland patients
    (excluding newborns) including trauma who were treated between January 1, 2010 and March 31,
    2010.

     One chart was removed from the sample due to not being a first time Parkland Patient.

     • One of 18 (6%) medical records reviewed did not have a signed Acknowledgment Form showing
       the patient's receipt of the Privacy Notice, nor indication of decline.

     • One of 19 (5%) medical charts could not be located by the Ambulatory Surgery Center.

     In 2009, 2 of 19 (10%) of medical records reviewed did not have a signed Acknowledgment Form
     showing the patient's receipt of the Privacy Notice; a decrease of 4% has been noted for 2010.

     In addition, IAS noted that current practice is to allow patients to decline or refuse to sign or
     complete the Acknowledgement Forms and the guidelines had not been updated to reflect the
     current practice at the time of review.

        Management Response: Brad Simmons, Senior Vice President of Surgical Services
        Surgical Services has requested the chart from HIM to determine the location of the form and will
        take necessary actions to assure all forms are completed.

        Management Response: Sharon Phillips, Senior Vice President of Community Medicine
        Agree. We were unable to locate one of the Patient Statement of Responsibility forms of the
        accounts observed. The obtainment of the Patient Statement of Responsibility form at the point
        of Registration is an element in which we monitor to ensure compliance. COPC will continue to
        monitor and reinforce compliance of this requirement.
        Targeted Completion Date: October 11, 2010

        Management Response: Nancy Merritt, Vice President & Compliance Officer
        We will continue to educate registration employees on the importance of providing patients with
        the Notice of Privacy Practices and obtaining documentation of their acknowledgment of receipt.

3. High Profile Patients: IAS contacted Corporate Communications to identify a high profile patient
   population. Corporate Communication provided two high profile patients treated in 2009. IAS verified
   in EPIC their admission and discovered they were admitted under their real names.

   Although some areas assign an alias to high profile patient, Parkland does not have a formal
   procedure to ensure high profile patient’s identities are protected.

        Management Response: Miriam Sibley, Senior Vice President and Chief Nursing Officer
        A policy will be developed to address VIP patients and the appropriate use of an alias.
        Targeted Completion Date: January 2011

4. Point of Disclosure- Breast Imaging Center: Internal Audit Services visited the Breast Imaging
   Center and requested to see their disclosure request log. IAS was informed that there was no log
   because no information was being released.

   All requests are being submitted through Parkland’s Health Information Management Department.




                                                    A-4
DALLAS COUNTY HOSPITAL DISTRICT
PARKLAND HEALTH & HOSPITAL SYSTEM


INTERNAL AUDIT SERVICES
HIPAA Monitoring, Fiscal Year 2010 – 3th & 4th Quarters, Report No. 2010-501

5. Breach Notification for Unsecured PHI: Internal Audit Services requested procedures from
   Compliance for reporting breaches of unsecured patient health information.

    At the time of the review, Parkland had not had any security breaches requiring notification.
    However, a draft procedure has been developed as of November 2009. Information Security along
    with Compliance has developed a process to report security breaches of unprotected health
    information in a timely and efficient manner.

6. Accounting of Disclosures: Internal Audit Services requested from Compliance a log of accounting
   disclosures made in Fiscal Year 2010 and reviewed Parkland’s Administrative Guidelines.

    IAS could not conduct testing because per the Compliance Director, no accounting of disclosures had
    been requested in Fiscal Year 2010.

    IAS also noted that Parkland’s HIPAA Administrative Guidelines do not reflect changes indicated by
    the ARRA Act of 2009. New HITECH language states that Parkland must include our business
    associates, as well as their business associates in any accounting of disclosure requests; however,
    this requirement has not been finalized.

IAS would like to thank Radiology, Health Information Management, Legal Affairs, Patient Financial
Services, Ambulatory Surgery Center, Information Security, Community Oriented Primary Care, and
Corporate Compliance for their assistance during this review.

Responsible Management:

Surgical Services / Ambulatory Surgery Center:
Executive Vice President & Chief Operating Officer: John Haupert
Senior Vice President: Brad Simmons
Director of Ambulatory Services: Suzanne Sims

Clinical Support / Radiology:
Executive Vice President & Chief Operating Officer: John Haupert
Senior Vice President: Vicki Crane
Director of Radiology: Geoffrey Camp

Revenue Cycle / Patient Financial Services:
Executive Vice President & Chief Financial Officer: John Dragovits
Vice President of Revenue Cycle: Richard Rhine
Director of Patient Access: Bob Reed

Information Security:
Executive Vice President & Chief Financial Officer: John Dragovits
Senior Vice President & Chief Information Officer: Jack Kowitt
Deputy Chief Information Officer: Nancy Folz-Murphy
Director of Information Technology & Security: James Carpenter

Corporate Compliance:
Vice President & Compliance Officer: Nancy Merritt
Director of Privacy/Privacy Officer: Cathy Haliburton

Legal Affairs:
Deputy General Counsel: Kenya Woodruff, J.D.




                                                   A-5
DALLAS COUNTY HOSPITAL DISTRICT
PARKLAND HEALTH & HOSPITAL SYSTEM


INTERNAL AUDIT SERVICES




DATE:    October 13, 2010


TO:      Audit & Compliance Committee
         PHHS Board of Managers


FROM:    Vic Summers, Senior Vice President
         Internal Audit Services


RE:      Audit Management Response Follow-up Audit, Fiscal Year 2010 – 3rd and 4th Quarters


         Attached please find our summary report on the Audit Management Response Follow-up
         Audit for Fiscal Year 2010 – 3rd and 4th Quarters. We are e-mailing the summary detail due
         to the volume. Printed copies will be provided at the meeting for your reference.


         Regards.




         Attachments

CC:      Ron J. Anderson, M.D., President & Chief Executive Officer
         John Dragovits, Executive Vice President & Chief Financial Officer
         John Haupert, Executive Vice President & Chief Operating Officer
         John Shannon, M.D., Executive Vice President & Chief Medical Officer
         Tim Bahe, Executive Director, Parkland Community Health Plan
         Frank Hemeon, Senior Vice President & Assistant Chief Financial Officer
         Candy Knowles, Senior Vice President & Chief Human Resources Officer
         Jack Kowitt, Senior Vice President & Chief Information Officer
         Vicki Crane, Senior Vice President, Clinical Support Services
         Josh Floren, Senior Vice President, Medicine Services
         Walter Jones, Senior Vice President, Facilities
         Sharon Phillips, Senior Vice President, Community Medicine
         Bradley Simmons, Senior Vice President, Surgical Services
         Paula Turicchi, Senior Vice President, Women & Infants’ Specialty Health
         Liz McMullen, Vice President & Controller, Finance
         Nancy Merritt, Vice President & Chief Compliance Officer, Corporate Compliance
         Shelly Monks, Vice President, Medical Affairs
         Andrew Montgomery, Vice President, Supply Chain
         Richard Rhine, Vice President, Revenue Cycle
         Robin Stults, Vice President, Health Information Management
DALLAS COUNTY HOSPITAL DISTRICT
PARKLAND HEALTH & HOSPITAL SYSTEM


INTERNAL AUDIT SERVICES
Audit Management Response Follow-up Audit, Fiscal Year 2010 – 3rd and 4th Quarters
October 13, 2010




              Responsible                      IAS
  Risk                               Total             < 6 months   6 months - 1 year   1 - 2 years   > 2 years
              Management                     Testing

High       Andrew Montgomery          1         0                                           1

High       Brad Simmons               4         1                                           4

           Brad Simmons,
High                                  1         0                                           1
           Jack Kowitt

High       Jack Kowitt                1         0            1

High       John Haupert               1         1            1

           John Shannon,
High                                  1         1                                           1
           Shelly Monks

High       Vicki Crane                4         1            4

High       Walter Jones               2         2            2

Moderate   Andrew Montgomery          2         0            2

Moderate   Brad Simmons               3         1                                           2            1

Moderate   Frank Hemeon               9         4                          4                5

Moderate   Jack Kowitt                1         0                          1

Moderate   John Shannon               1         1                          1

Moderate   Josh Floren                1        0                                                         1

Moderate   Paula Turicchi             4         1            3                                           1

Moderate   Richard Rhine              1         0            1

Moderate   Robin Stults               1         1            1

Moderate   Vicki Crane                5         0            4             1

Moderate   Walter Jones               2         2            2

Low        Brad Simmons               1        1                                            1


                            Totals    46       17            21            7                15           3




                                                       B-2
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management                 Target     Complete    Observation Title & Auditor Comments
               Report Date                           Original Management Response               Date        Date       and/or Follow Up Mgmt Responses


2009-004 Pharmacy Administration                  Vicki Crane                                 7/31/2007   7/13/2010
6/13/2007                                                                                                             3. Medication Overcharges

2009-006 Equipment Rental                         Vicki Crane                                 6/1/2010    8/5/2010    a. Equipment Tracking
9/22/2009                                                                                                             1. Equipment Tracking and Invoice
                                                                                                                      Reconciliation

2009-006 Equipment Rental                         Vicki Crane                                 6/1/2010    8/5/2010    b. Equipment and Other Rentals
9/22/2009                                                                                                             1. Equipment Tracking and Invoice
                                                                                                                      Reconciliation

2009-015 Respiratory Care                         Vicki Crane                                 Status In
3/23/2010                                                                                     Progress                1. Epic Orders to Charges

IAS selected 30 patients and traced the orders    Respiratory Care is developing training     5/1/2010                IAS requested documentation and details
to the procedures performed and the               to retrain and reinforce all staff in                               of the staff training on 6/29/10.
subsequent charges generated. During this         documentation and charging                                          Reminder sent on 9/30/10.
testwork, IAS identified the following            procedures. Training to be completed by
deficiencies:                                     May 1, 2010.                                                        Follow Up Management Response:
1. 4 out of 30 (13%) patients had errors:                                                                             According to Respiratory Care
     each error was attributable to employees                                                                         management, all staff was trained on
     not following established procedures.        A short-term resolution to this issue                               continuous charge procedure documented
2. Three errors (10%) resulted in overbilling     would be to develop and implement a                                 through the Learning Management System
     the patient: Two patient's orders were not   bidirectional interface between                                     by May 1, 2010. Module - Continuous
     discontinued and one patient had pulse       CliniVision & EPIC. This would provide                              Charge Procedure.
     oximeter activity that was not documented    staff with a structured means of entering
     by the employee.                             orders and treatment documentation.
3. One patient's (3%) orders were not             This interface would reduce errors
     entered into CliniVision as required by      associated with the human element
     Respiratory Care procedure. However, the     while ensuring proper billing.
     patient was treated as ordered.

During this testwork IAS noted that it is         Long term, the recommendation is to
unclear whether the physician intends, or is      replace CliniVision with EPIC for all
aware that, protocols will automatically be       Respiratory Care activities, however
used when treating the patient.                   additional development work would be
                                                  required by EPIC to accomplish this
                                                  goal.


                                                                                 B-3
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                   Target     Complete   Observation Title & Auditor Comments
                Report Date                           Original Management Response                 Date        Date      and/or Follow Up Mgmt Responses


2009-015 Respiratory Care                          Vicki Crane                                   Status In
3/23/2010                                                                                        Progress               2. Charge Interface

IAS tested patient charges by selecting a          Respiratory Care can identify individual      5/15/2010              Requested the status of the service ticket
sample of 30 Clinivision procedures and            charges by patient sent across the                                   on 6/30/10.
tracing to the related charge. In a second test,   interface for billing. This report could be                          Reminder sent on 9/30/10.
a sample of 30 physician orders were selected      compared with billing data from Epic to
and traced to the related charge.                  ensure accurate billing is achieved.                                 Follow Up Management Response:
1.         IAS testing of 30 transactions from     Respiratory Care will work with IT to                                According to Respiratory Care
     Clinivision identified that the charges for   develop a reconciliation procedure by                                management report is currently available in
     three procedures for one patient were not     May 15, 2010.                                                        CliniVision to verify patient charges.
     captured in Epic billing. IAS tracked the     The aforementioned bidirectional                                     Request submitted to Enterprise Reporting
     procedures from the orders to the billing     interface between CliniVision & EPIC                                 Team for Epic report of daily Respiratory
     file sent from Clinivision. However the       would allow charges to be processed by                               Care charges, ticket 256579.
     charges could not be located in Epic          EPIC instead of CliniVision, thus
     billing.                                      removing any potential of missed or
     The IT department stated that this was        duplicate charges from CliniVision. (The
     due to a hard drive failure of the            bidirectional interface(s) would not
     Clinivision Communication Server in July      impact the billing workflow due to
     2009. It was reinstated a few days later      application limitations. We would
     and required vendor assistance. All           recommend not using this point until we
     charges for this period had to be re-         could further explore this possibility).
     submitted for billing in different batches    Respiratory Care will work with IT to
     due to system limitations. According to       ensure there are no systematic
     Information Systems, the missed charges       problems with the charge interface until
     identified by IAS were not included in the    such time as documentation and
     charges that were re-submitted.               charging are moved to Epic.
     IAS did not find any risk mitigation          Respiratory Care will work with IT to
     procedures for hardware/software failures     develop a procedure to monitor billing
     and processes to ensure that all charges      sent from CliniVision across the
     are resubmitted upon restoration of the       interface with data returned from Epic.
     system.                                       Procedure to be complete by May 15,
2.         IAS testing of 30 Epic transactions     2010.
     identified a duplicate charge. Per
     Respiratory Care, the charge was sent to
     the interface one time, but it appears on
     the patient’s account in Epic twice.



                                                                                   B-4
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management                  Target     Complete   Observation Title & Auditor Comments
               Report Date                           Original Management Response                Date        Date      and/or Follow Up Mgmt Responses


2009-015 Respiratory Care                         Vicki Crane                                  Status In
3/23/2010                                                                                      Progress               3. Compliance with Standards

IAS review of Clinivision indicated the           CliniVision is currently not able to meet    5/1/2010               According to Respiratory Care
following deficiencies with regard to             the HIPAA standard for audit trails and                             management, CliniVision Password
compliance with HIPAA and Information             there are no immediate plans to                                     Settings were updated to meet standards
Security Standards:                               upgrade this feature in the software. A                             11/09. Waivers for use of PC Anywhere
     1. The audit trails in Clinivision are not   Security Risk Acceptance has been                                   and HIPAA guidelines were signed & in
        monitored as required by HIPAA            written and signed by departmental                                  place prior to 5/1/2010.
        standards and implementation              staff, Sr. Vice President and is on file
        specifications because the system         with Information Security as of                                     Requested a copy of the waivers on
        lacks adequate tools for monitoring.      11/12/2009. Because of this and other                               6/30/10. Reminder sent on 9/30/10.
     2. Clinivision uses PC Anywhere for          system deficiencies, Respiratory Care
        access between Clinivision and            would recommend working with EPIC to
        Cloverleaf (Interface). Although PC       develop the necessary functionality that
        Anywhere is properly installed            would ultimately allow Respiratory Care
        according to PHHS Information             to migrate off of CliniVision in favor of
        Security Standards, Respiratory Care      using EPIC for all respiratory activity.
        has not obtained the authorized risk      A Security Risk Acknowledgement for
        waiver from Information Security as       the use of PC Anywhere for billing file
        required by the standards. The waiver     transfer through the Cloverleaf interface,
        ensures that the scope of the             has been written and signed by
        connectivity application is approved      departmental staff, Sr. Vice President
        by the Information Security               and is on file with Information Security
        Department.                               as of 2/15/10.
     3. Respiratory Care Department, who is       Respiratory Care is in the process of
        responsible for the system                developing and revising system
        administration including security does    administration procedures in
        not have documented administration        accordance with PHHS Information
        procedures.                               Security Standards to be completed by
     4. The password management for               May 1, 2010.
        Clinivision were not in compliance        CliniVision password policy was
        with PHHS Information Security            changed to meet PHHS Information
        Standards. During the course of the       Security Standards on 10/14/2009. The
        audit changes were made to the            Respiratory Care department will
        security configuration to ensure          monitor PHHS Information Security
        compliance.                               Standards on an on-going basis to
                                                  ensure compliance.


                                                                                 B-5
                                                         Parkland Health & Hospital System
                                                               Internal Audit Services
                                                         Audit Follow-Up Summary Report
                                                           Fiscal 3rd & 4th Quarters 2010
                                                    All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                       Responsible Management                Target     Complete     Observation Title & Auditor Comments
                Report Date                            Original Management Response              Date        Date        and/or Follow Up Mgmt Responses


2009-015 Respiratory Care                           Vicki Crane                                Status In
3/23/2010                                                                                      Progress                4. Clinivision Contract

Parkland's copy of the contract with Puritan        Respiratory Care will work with Legal      3/10/2010               IAS is trying to determine the contract
Bennet (Nellcor) shows that the contract had        and the OCIO to ensure the CliniVision                             status. Email to Respiratory Care on
expired in October 2007. IAS has learned            contract is current and inclusive of all                           6/30/10. Reminder sent on 9/30/10.
from the OCIO that ownership of the firm had        devices using the system.
changed hands several times and the last                                                                               According to Respiratory Care
payment for support services, made to                                                                                  management, the task is assigned to CIO
Mallinckrodt, Inc. covers a period ending June                                                                         for follow up.
2009. Respiratory Care did not have any
additional information because the payments
and authorizations are made by the OCIO.
IAS also noted that the terms of the old
contract such as the number of annual
support for hand-held devices were higher
than actual number of devices used by the
Respiratory Care Department.

2009-208 Radiant                                    Vicki Crane                                9/30/2009   4/27/2010
9/22/2009                                                                                                              03. Reason for Examination

2010-002 Radiology Administration                   Vicki Crane                                 Status                 c. Diagnosis
5/25/2010                                                                                       Open                   2. Coding Compliance

Five of the 22 (23%) procedures reviewed            Action Plan to be submitted by HIM         5/13/2010               Documentation was provided by HIM on
have diagnosis code reporting errors. Of those                                                                         6/30/10 indicating coder education had
5 with errors (note that a claim for one                                                                               been provided in June, 2010. This training
radiology procedure may have multiple                                                                                  covered the guidelines for outpatient
diagnosis reporting errors):                                                                                           services coding and reporting as well as
    1. 3 diagnosis codes are missing,                                                                                  PHHS HIM-specific coding and abstracting
         resulting in a lack of medical necessity                                                                      guidelines.
         justification for the procedures
         performed; and                                                                                                IAS will test a sample of 10 records for
    2. 3 diagnosis codes are incorrectly                                                                               diagnosis accuracy at the time testing is
         reported, one of these resulting in a                                                                         performed for charge capture accuracy in
         lack of medical necessity justification                                                                       early November.



                                                                                   B-6
                                                         Parkland Health & Hospital System
                                                               Internal Audit Services
                                                         Audit Follow-Up Summary Report
                                                           Fiscal 3rd & 4th Quarters 2010
                                                    All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                       Responsible Management               Target     Complete    Observation Title & Auditor Comments
                Report Date                            Original Management Response             Date        Date       and/or Follow Up Mgmt Responses


        for the procedures performed.

Although the errors noted are not all
government payor accounts, diagnosis codes
are assigned according to chart
documentation for all payors.

2010-002 Radiology Administration                   Vicki Crane                                Status                 Time Out Checklist
5/25/2010                                                                                      Open                   3. Time Outs

"Time Out" allows the nurse or technologist         • Agree with findings. The department     5/13/2010               The time out documentation process is
and the providers to conduct a final                has implemented an electronic time out    11/1/2010               being updated. New target completion date
verification of correct patient, procedure, site,   process within Epic. This process went                            is 11/1/10.
and side before an invasive procedure is            live on 4/27/2010. Audits will begin in
initiated. IAS randomly selected 30 patients        June 2010 to ensure compliance with
who received Radiology procedures requiring         hospital time out policy.
a time out from April 2009 to October 2009.
Medical records were requested from HIM to
locate the time out checklist and verify the
required attributes.

IAS noted that for five of 30 (17%) patients
receiving an invasive radiology procedure a
time out checklist was not located in the chart.
Fourteen of 25 (56%) timeouts were
incomplete.


2010-002 Radiology Administration                   Vicki Crane                               5/13/2010   8/25/2010   a. COPC Professional Readings
5/25/2010                                                                                                             5. Contracts

2010-002 Radiology Administration                   Vicki Crane                               5/13/2010   8/25/2010   b. PET Pre-Approvals
5/25/2010                                                                                                             5. Contracts

2010-002 Radiology Administration                   Vicki Crane                                Status                 a. National Breast Cancer Foundation
5/25/2010                                                                                      Open                   (NBCF)
                                                                                                                      6. Grants



                                                                                  B-7
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management                  Target     Complete    Observation Title & Auditor Comments
               Report Date                           Original Management Response                Date        Date       and/or Follow Up Mgmt Responses


NBCF allows grant funding of mammograms           • Agree with findings. After investigation   5/13/2010               IAS reviewed a sample of 10 July National
up to the published local Medicare rate for the   the finding was due to human error. The                              Breast Cancer Foundation recipients to
mammogram procedures. For 30 of 30 (100%)         employee has been re-educated on the                                 determine if the reimbursement rate was
patients Breast Imaging requested                 correct charging process for established                             not greater than the published Medicare
reimbursement from the Parkland Foundation        grants.                                                              rate. All 10 visits were reimbursed at a rate
for the amount Parkland charges for each                                                                               greater than the published Medicare rate.
procedure not the published Medicare rate.
The reimbursement was $5249 greater than
allowed for the 30 patients. Reimbursing at
the higher rate depleted the budgeted funds
before the original estimated number of
patients were seen. Visits that the grant
funding was applied to occurred from July 09
to September 09.

2010-002 Radiology Administration                 Vicki Crane                                   Status                 b. National Breast Cancer Foundation
5/25/2010                                                                                       Open                   6. Grants

NBCF requires that the patient have an            • PFS has implemented the process that       5/13/2010               IAS selected a sample of 10 patients who
income below 200% of the Federal poverty          patients who qualify for NBCF grant and                              were placed on the National Breast Cancer
level and have no medical insurance or have       who are enrolled on PHP will be given                                Foundation (NBCF) grant in July and seven
a co-pay that makes it difficult for them to      the NBCF Coverage due to the fact that                               of 10 (70%) patients did not have PHP
access care. IAS requested supporting             they have already been screened for                                  coverage at the time they were placed on
documentation showing the financial status for    PHP and have been determined eligible                                the NBCF grant.
patients receiving grant funding. IAS noted       because their income is at or below
Financial Counselors do not verify the            200% of the Federal Poverty Limits.
patient's ability to pay prior to adding grant    PFS is only giving the NBCF grant to
funding to the account. A verbal declaration is   those who are already enrolled on PHP.
accepted.                                         PFS decided not to add NBCF into
                                                  Medicaider considering the PHP
                                                  patients have already been screened
                                                  through the Medicaider process, and
                                                  determined to be under the 200%
                                                  poverty level.

2010-002 Radiology Administration                 Vicki Crane                                  5/13/2010   9/28/2010   c. Susan Komen
5/25/2010                                                                                                              6. Grants



                                                                                  B-8
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                 Target     Complete    Observation Title & Auditor Comments
                Report Date                           Original Management Response               Date        Date       and/or Follow Up Mgmt Responses


2010-002 Radiology Administration                  Vicki Crane                                 Status                  Use and Distribution
5/25/2010                                                                                      Open                    8. Personal Dosimeter Use and Distribution

As described in Radiology Procedure J-28,          • A new policy has been written based       8/1/2010                IAS has requested information from the
Personal Dosimeter/Use and Distribution,           on best practices. A new sign in/out log                            department as of 10/6/10. IAS will select a
personal dosimeters will be disseminated and       has been completed, and an Access                                   sample and begin testing upon receiving
retrieved monthly to determine the amount of       database is under construction for                                  information.
radiation exposure received. IAS randomly          employee badge management. The
selected 30 employees from the Radiology           process will be audited quarterly.
locations where Ionizing radiation and
isotopes (radioactive) are emitted. IAS verified
that from April 2009 - September 2009 each
technologist signed a log sheet indicating
he/she received a new badge and deposited
the used badge. In addition, IAS verified the
same individuals appeared on reports from
Radiation Safety indicating the dosimeter was
tested timely. IAS noted the following.
1. All employees in areas where ionizing
     radiation and isotopes are emitted are not
     signing monthly dosimetery logs indicating
     the old badge was turned in and a new
     one was received.
2. Collected badges are not being submitted
     on a monthly basis for reading according
     to departmental procedure.

2009-005 Contract Labor                            John Dragovits                             10/31/2009   5/14/2010   a. Contracts greater than $200,000
6/19/2009                                                                                                              1. Board of Managers

2009-005 Contract Labor                            John Dragovits                             10/31/2009   5/14/2010   c. Multiple Purchase Order Numbers
6/19/2009                                                                                                              2. Procurement Process

2009-005 Contract Labor                            John Dragovits                             12/31/2009   5/14/2010   e. Outdated Policies
6/19/2009                                                                                                              2. Procurement Process

2009-005 Contract Labor                            John Dragovits                             12/31/2009   5/14/2010   a. Contracts
6/19/2009                                                                                                              2. Procurement Process


                                                                                  B-9
                                                      Parkland Health & Hospital System
                                                            Internal Audit Services
                                                      Audit Follow-Up Summary Report
                                                        Fiscal 3rd & 4th Quarters 2010
                                                 All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                     Responsible Management                  Target     Complete      Observation Title & Auditor Comments
               Report Date                          Original Management Response                Date        Date         and/or Follow Up Mgmt Responses


2009-005 Contract Labor                          John Dragovits                              10/31/2009   5/14/2010    f. Distribution Accounts
6/19/2009                                                                                                              2. Procurement Process

2009-005 Contract Labor                          John Dragovits                              12/31/2009   5/14/2010    b. Generating Purchase Orders
6/19/2009                                                                                                              2. Procurement Process

2009-005 Contract Labor                          John Dragovits                              10/31/2009   5/14/2010    d. Woman/Minority Business Enterprise
6/19/2009                                                                                                              2. Procurement Process

2008-011 Psych Clinic                            Josh Floren                                 6/16/2008    10/5/2010    a. Certification/Re-certification for
7/22/2008                                                                                                              Medicare Patients
                                                                                                                       1. Medical Necessity

2008-011 Psych Clinic                            Josh Floren                                 Status In                 b. Unsigned Bill of Rights
7/22/2008                                                                                    Progress                  2. Incomplete Chart Documentation

For 1 of 20 patients who received emergent or    Prior to discharge from the Psych ER,       6/16/2008                 As of 10/11/10, IAS has not received 2 of
inpatient psychiatric treatment between 1/9/08   the HUC checks each patient’s chart for     4/15/2010                 10 charts requested from Health
and 1/11/08 (5%) , the Bill of Rights was not    the presence of a signed Patient Bill of                              Information Management. For 1 of 8
signed by a staff member. For a second           Rights or documentation about why the                                 patients tested (13%), clinical staff did not
patient (5%), the staff member who signed the    form was not signed. When doing initial                               document why the patient did not sign the
Bill of Rights did not document why the          chart checks following patient admission                              Bill of Rights.
patient's signature was missing.                 to 8 North, the Primary Nurse and/or
                                                 Unit Manager will check for the
                                                 presence of a signed Bill of Rights form.
                                                 Patients will be offered the opportunity
                                                 to sign the form at the time of admission
                                                 to 8 North.


2008-011 Psych Clinic                            Josh Floren                                 6/12/2008    10/11/2010   a. Medication Overcharges
7/22/2008                                                                                                              3. Charge Capture

2008-011 Psych Clinic                            Josh Floren                                 6/12/2008    5/21/2010    f. Missed Charges
7/22/2008                                                                                                              3. Charge Capture

2008-011 Psych Clinic                            Josh Floren                                 6/16/2008    5/21/2010    g. Late Charge Postings
7/22/2008                                                                                                              3. Charge Capture



                                                                               B-10
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                  Target     Complete     Observation Title & Auditor Comments
                Report Date                           Original Management Response                Date        Date        and/or Follow Up Mgmt Responses


2009-013 Grant Management                          Josh Floren                                  3/10/2010   9/30/2010   b. 100% Grant Funded
3/23/2010                                                                                                               3. Board Reporting

2010-005 Engineering Services                      John Haupert                                  Status                 a. Authorized Drivers
8/24/2010                                                                                        Open                   1. Hospital Owned Vehicles

According to Fiscal Policy 8311-3-05 (Motor        Departments with drivers will maintain a     9/30/2010               Testing will be performed in the first quarter
Vehicles), each Department Director who            list. Annually, the drivers list will be                             of Fiscal Year 2011.
manages the use of a Parkland owned vehicle        given to the Police Department to verify
is to provide a list of all employees authorized   driving records. HR will continue to
to drive that vehicle to the Department of         verify driving records at date of hire. In
Legal Affairs. However, the current process is     addition, job descriptions will be
such that when an employee is requested to         reviewed to ensure positions accurately
be added to the authorized drivers list, Human     reflect the requirement to drive.
Resources (HR) processes the driving record
with Group One. Once it is clear, HR notifies
the Department. Legal Affairs is not notified.
To determine if hospital owned vehicles are
being properly utilized by authorized
individuals, IAS randomly selected 30
individuals from the Engineering vehicle sign-
out logs for October 2009 through March 2010
and verified they appeared on Engineering's
authorized drivers list. IAS noted five of 30
(17%) employees did not appear on
Engineering's authorized drivers list. However,
these five employees did appear on the
authorized driver list provided by Human
Resources. Three of the five drivers are
employed by Clinical Engineering, but operate
Engineering vehicles periodically. One
employee is no longer with Parkland. One
employee is an offsite COPC Engineering
employee.
In addition, IAS randomly selected 30
employees from the authorized drivers list
kept by Engineering and had the Parkland
Police verify their driving records. At the time


                                                                                  B-11
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management                 Target     Complete   Observation Title & Auditor Comments
               Report Date                           Original Management Response               Date        Date      and/or Follow Up Mgmt Responses


of the review, two of 30 (7%) Engineering
employees who appear on the Engineering
authorized driver list did not have a valid
Texas Driver’s License. One of the two
employees did not appear on the authorized
driver list provided by Human Resources.
Both employee job descriptions require a valid
Texas Class C Driver License, and to be
insurable. The vehicle sign out logs for FY
2010 do not indicate that either of the two
employees operated a vehicle in FY 2010.
Parkland Police verified the driving records of
drivers hospital wide and identified two
additional employees that did not have a valid
drivers license. These two employees are not
employed by Engineering.

2008-015 Fixed Asset and General Ledger           Frank Hemeon                                Status In              3. Capital Projects with Untagged Capital
11/19/2008                                                                                    Progress               Equipment

Of six projects that included capital equipment   Agree. Historically, Accounting has         1/31/2009              IAS tested a selection of ten items. Each
purchases, four projects (67%) had one or         capitalized equipment upon completion       3/31/2010              item appeared to have been capitalized
more untagged capital equipment items. After      of the project. Accounting will develop a                          and input into Lawson in a timely manner;
the audit, Accounting issued property tags for    formal procedure to review projects on a                           however, nine of the ten items selected did
the untagged items.                               monthly basis and capitalize equipment                             not have a tag according to the various
    1. Hospitalist Unit on 6 South: Two beds      as it is acquired.                                                 groups.
         (valued at $15,036.02) and an
         electrocardiogram machine (valued at
         $11,458.64) were not tagged.
         Additional details are provided under
         the observation titled "General Ledger
         Accuracy."
    2. Wound Care: A stainless steel cart
         valued at $27,900 was not tagged
         because Accounting did not know
         where to send the tag. The cart was
         capitalized separately from the
         project.. IAS informed Accounting that


                                                                                B-12
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management                  Target     Complete    Observation Title & Auditor Comments
               Report Date                           Original Management Response                Date        Date       and/or Follow Up Mgmt Responses


       the property tag should go to the
       Physical Therapy Department.
    3. Voluson 730 Expert Upgrade: An
       ultrasound machine valued at $50,000
       was not tagged because Accounting
       thought the project only involved
       software and hardware purchases.
    4. Security High Risk Electrical and
       Mechanical Rooms: A 16 port DVR
       machine was not tagged, although it
       was valued at $7,208. After IAS
       identified this issue, Accounting
       capitalized the DVR machine
       separately from the project.

In regard to capital projects, Fiscal Manual
Procedure 8311-5-10 (Project Authorization,
Accounting and Capitalization) states the
following: "Equipment is capitalized separately
and property tags are issued for each piece of
equipment over $5,000 in value."

2008-015 Fixed Asset and General Ledger           Frank Hemeon                                 Status In
11/19/2008                                                                                     Progress               4. General Ledger Accuracy

The GEAC Millennium (General Ledger)              Agree. The Material Resource                 11/5/2008              IAS to test in the first quarter of Fiscal Year
system had no record of the property tag          department was entering capital assets       9/30/2010              2011.
numbers affixed to 15 beds on 7 South             into the property ledger until May, 2007,
(Hospitalist Unit). Two beds and an               when this function was transitioned back
electrocardiogram (ECG) machine were listed       to Accounting. It took several months to
on the General Ledger but were not tagged.        reconcile and update the property
The beds were purchased for $127,806.17           ledger. Accounting will work with Supply
and the ECG machine for $11,458.64 in Fiscal      Chain management to determine the
Year 2007.                                        feasibility of transitioning this function
Upon further investigation, Accounting            back to them in conjunction with the
concluded that the Material Resources             implementation of a new fixed asset
Department (MRD) issued the property tags         system in fiscal year 2010.
without entering the tag numbers into the


                                                                                 B-13
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                 Target     Complete   Observation Title & Auditor Comments
                Report Date                           Original Management Response               Date        Date      and/or Follow Up Mgmt Responses


property ledger. Miscommunication between
Accounting and the Operating Room (OR)
resulted in the equipment being assigned to
the OR under a different series of tag
numbers. In September 2008, Accounting
corrected the cost center in Millennium.
Accounting also sent replacement tags for the
17 beds and the ECG machine.
As stated in Fiscal Procedure 8311-5-09,
"Property and Equipment Control," capital
assets should be logged into the property
ledger.

2008-018 Payroll                                   Frank Hemeon                                Status In
2/24/2009                                                                                      Progress               2. Payroll Accuracy

Internal Audit validated the accuracy of payroll   b), c), d), e), f)                          4/30/2009              Finance has addressed items c, d, and e.
for one pay period. As part of the test, IAS       Currently, Payroll Processing distributes                          The following items remain in progress as
looked at paycheck accuracy, overtime,             two payroll exception reports to senior                            of 5/21/2010:
payroll controls, miscellaneous pay                management. The T&L Editor Audit                                   b) Three of 10 (30%) payments were
categories, and employee benefit                   report notes unusual edits for                                     corrected for over payments. One of 10
reimbursement. Internal Audit identified the       management review and is issued on a                               (10%) payment was incorrect due to
following:                                         bi-weekly basis. The Overtime Report                               incorrect prescription refund. f) Two of 10
a) A clocking employee was paid for two pay        notes all employees that were paid                                 (20%) employees were coded education
periods (a total of 124 hours) after terminating   more than 16 hours of overtime during                              pay by mistake.
from the organization. The Time & Labor            the pay period. This report has been
Editor continued to edit the employee's time       generated on a quarterly basis, but has
and the termination form was not completed         now been changed to a bi-weekly
until IAS notified HR of the situation. The        report. Currently, both reports are
paychecks have not been picked up.                 distributed in hard copy, but should be
b) Two employs were shorted hours on their         available in an electronic format by
checks as a result of inaccurate editing, one      March 31, 2009. The Financial
employee by 40 hours and the other by 16           Operations Analysts are also aiding in a
hours.                                             review of overtime by division to
c) Of the 60 employees who had over 80             determine causes and assist with action
hours of regular time in the sample pay            plans to manage overtime in the most
period, the following was noted:                   cost efficient way. In addition, the
     1. Thirteen employees (22%) were paid         Payroll Processing staff will provide


                                                                                 B-14
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management             Target   Complete   Observation Title & Auditor Comments
               Report Date                           Original Management Response           Date      Date      and/or Follow Up Mgmt Responses


       over 80 hours of regular time in error,    additional training and education
       which resulted in overpayments             (working in conjunction with HR) to
       totaling $15,000.                          ensure editors and managers know how
    2. Three employees (5%) had their chief       to properly edit and validate time.
       resident allowance pay as regular
       hours. Furthermore, the PTO (Paid
       Time Off) for all residents is coded as
       regular hours, which inflates the FTE
       (Full Time Employee) statistics for the
       respective department.
    3. Five employees (8%) received regular
       hour payment for previous time
       periods, not classified as off cycle.

d) Overtime for the sample pay period totaled
$804,323 and 24,111 hours (potentially over
300 FTE's). IAS sampled the top ten
employees with overtime hours (ranging from
31 to 47 hours) for that pay period and noted
that each occurrence was approved and the
departments are budgeting for the overtime.
However, IAS did not find any enterprise-wide
management analysis to justify the high
overtime usage. In addition, overtime reports
are not being consistently distributed to
departments for management review.
e) Seven of 30 employees sampled with the
jury duty pay code were inappropriately
assigned the pay code by the Time & Labor
Editor for the following reasons:
     1. One Employee (3%) received jury
         duty time instead of regular time.
     2. Two Employees (7%) coded jury duty
         for personal subpoenas, which should
         be personal time off (PTO) per policy.
     3. Four Employees (13%) did not have
         documentation to support jury duty.
f) One employee was paid from the Education


                                                                              B-15
                                                      Parkland Health & Hospital System
                                                            Internal Audit Services
                                                      Audit Follow-Up Summary Report
                                                        Fiscal 3rd & 4th Quarters 2010
                                                 All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                     Responsible Management             Target     Complete    Observation Title & Auditor Comments
               Report Date                          Original Management Response           Date        Date       and/or Follow Up Mgmt Responses


pay code instead of the New Employee
Orientation pay code.
g) IAS recalculated tuition reimbursement
amounts and verified payment accuracy in
PeopleSoft. One employee inaccurately
received a reimbursement due to a data entry
error. Another benefit reimbursement form for
tuition reimbursement did not reflect the
amount that had been approved. The
reimbursement was approved as a Graduate
Level Course for $1265, but the courses were
actually Undergraduate Courses. Benefits
reviewed the form and corrected the amount
to $860 prior to reimbursing the employee, but
the correction was never notated on the form.

2009-005 Contract Labor                          Frank Hemeon                            6/29/2010   5/14/2010   Check Request Payments
6/19/2009                                                                                                        3. Invalid payment method

2009-005 Contract Labor                          Frank Hemeon                           12/31/2009   9/16/2010   a. Missing W-9 forms
6/19/2009                                                                                                        4. 1099

2009-006 Equipment Rental                        Frank Hemeon                           12/31/2009   5/14/2010   b. Equipment and Other Rentals
9/22/2009                                                                                                        1. Equipment Tracking and Invoice
                                                                                                                 Reconciliation

2009-006 Equipment Rental                        Frank Hemeon                           12/31/2009   5/14/2010   c. Billing Discrepancies
9/22/2009                                                                                                        1. Equipment Tracking and Invoice
                                                                                                                 Reconciliation

2009-006 Equipment Rental                        Frank Hemeon                           12/31/2009   5/14/2010
9/22/2009                                                                                                        5. Distribution Accounts

2009-012 Travel                                  Frank Hemeon                           11/30/2009   5/21/2010   a. Quality Control Review
10/27/2009                                                                                                       1. Business Expense Reimbursements

2009-012 Travel                                  Frank Hemeon                           11/30/2009   5/21/2010   b. Insufficient Documentation
10/27/2009                                                                                                       1. Business Expense Reimbursements



                                                                             B-16
                                                         Parkland Health & Hospital System
                                                               Internal Audit Services
                                                         Audit Follow-Up Summary Report
                                                           Fiscal 3rd & 4th Quarters 2010
                                                    All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                       Responsible Management                    Target     Complete    Observation Title & Auditor Comments
                Report Date                            Original Management Response                  Date        Date       and/or Follow Up Mgmt Responses


2009-012 Travel                                     Frank Hemeon                                  10/31/2009   5/21/2010   c. Per Diems
10/27/2009                                                                                                                 1. Business Expense Reimbursements

2009-012 Travel                                     Frank Hemeon                                   Status                  d. Guests
10/27/2009                                                                                         Open                    1. Business Expense Reimbursements

Regarding spouse travel, the Fiscal Manual          Although it is not practical for Payroll      11/30/2009               As of 6/4/10, one employee traveled with a
8311-6-05 states that all costs related to          Processing to contact each hotel to                                    guest; the reimbursement documentation
spouse travel are not reimbursable including        determine the differential for multiple                                did not have an explanation of the guest
the differential in the hotel bill between one      occupants, in such cases as it appears                                 listed on hotel bill.
and two persons.                                    there are multiple occupants in the
IAS identified three instances where the            room, Payroll Processing will require the
employee traveled with family and the hotel         names of the individuals occupying the
room was rated for multiple occupants and the       room, and, if this includes family
employee was reimbursed for the entire bill.        members, will have the employee vouch
                                                    for the room rate differential.

2009-012 Travel                                     Frank Hemeon                                  10/23/2009   5/21/2010   e. Private Vehicle Transportation
10/27/2009                                                                                                                 1. Business Expense Reimbursements

2009-012 Travel                                     Frank Hemeon                                  11/30/2009   5/21/2010   f. Reservations
10/27/2009                                                                                                                 1. Business Expense Reimbursements

2009-012 Travel                                     Frank Hemeon                                  10/31/2009   5/21/2010   h. Car Rental
10/27/2009                                                                                                                 1. Business Expense Reimbursements

2009-012 Travel                                     Frank Hemeon                                   Status                  i. Lodging
10/27/2009                                                                                         Open                    1. Business Expense Reimbursements

Regarding lodging, Fiscal Manual 8311-6-05          Payroll Processing will review the            11/30/2009               As of 6/4/10, one employee booked on an
states that in many instances, a nearby hotel       lodging reimbursement request against                                  excessive costly hotel and the
is substantially less costly than the host hotel,   the conference brochure, which                                         reimbursements did not have an
the least costly alternative should be utilized.    generally references the cost of the host                              explanation or documentation to support
Transportation to and from a nearby hotel in        hotel, and which will be required                                      this being the least costly alternative.
lieu of the host hotel should be considered         documentation. The fiscal directive will
when determining the least costly alternative.      be revised to require an explanation for
However, IAS noted several lodging                  lodging at other than the host hotel if the
reimbursements that seemed excessive. For           hotel used is more expensive that the
example, a chosen hotel was more expensive          host hotel cost.

                                                                                   B-17
                                                      Parkland Health & Hospital System
                                                            Internal Audit Services
                                                      Audit Follow-Up Summary Report
                                                        Fiscal 3rd & 4th Quarters 2010
                                                 All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                     Responsible Management                Target     Complete    Observation Title & Auditor Comments
               Report Date                          Original Management Response              Date        Date       and/or Follow Up Mgmt Responses


and within walking distance from the
conference hotel and the individual rented a
car. Another of the chosen locations was a
bed and breakfast for $240/night, but the
conference hotel was only $189/night.

2009-012 Travel                                  Frank Hemeon                              10/31/2009   5/21/2010   j. Fiscal Procedures
10/27/2009                                                                                                          1. Business Expense Reimbursements

2009-012 Travel                                  Frank Hemeon                              Status In                2. Contractors
10/27/2009                                                                                 Progress                 2. Contractors

Regarding contractors, the Fiscal Manual         To date, Accounting has only reviewed     10/31/2009               IAS is in the process of identifying
8311-6-05 states that contractors and vendors    employee business reimbursements.                                  contractors with travel expense payments.
should follow Parkland’s reimbursement           Effective October 5, 2009, Accounts                                IAS will complete this testing during the
directive as closely as possible.                Payable will review vendor business                                first quarter of Fiscal Year 2011.
IAS reviewed contract reimbursements             reimbursements to assure
expense forms for five contractors/vendors to    appropriateness, and require an
verify the accuracy of calculations, valid       explanation and specific approval from
supporting documentation and proper              the division vice president for any
approvals. While it is Parkland's standard       unusual or potentially excessive
contract language to include a statement         reimbursements. The fiscal directive
saying the contractor should abide by            regarding business reimbursements will
Parkland's Travel Procedures,                    be revised to reflect this requirement.
reimbursements to contactors are not
following the travel procedures. IAS noted the
following issues:
     1. Three of 5 had no receipts for hotel,
         airfare, rental car, parking, etc.
     2. Two of 5 were reimbursed for mileage
         without enough supporting
         documentation (i.e. mileage log or
         internet map printout).
     3. Two of 5 did not have enough
         information to determine how meals
         were reimbursed.
     4. One of 5 was reimbursed for a rental
         car and gas, as well as mileage.


                                                                              B-18
                                                         Parkland Health & Hospital System
                                                               Internal Audit Services
                                                         Audit Follow-Up Summary Report
                                                           Fiscal 3rd & 4th Quarters 2010
                                                    All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                       Responsible Management                  Target     Complete   Observation Title & Auditor Comments
                Report Date                            Original Management Response                Date        Date      and/or Follow Up Mgmt Responses


    5. One of 5 was reimbursed for
       expenditure greater than 60 days.
    6. One of 5 was a reimbursement for a
       local contractor to travel from their
       home to Parkland.

2009-012 Travel                                     Frank Hemeon                                Status In               a. Credits
10/27/2009                                                                                      Progress                3. Credit Cards

IAS reviewed the cancellation process with          Credits can only be used by the initial     10/31/2009              As of 9/30/10, Travel Solutions has
Travel Solutions and determined that the            traveler and is good for only one year.                             provided list of credits and IAS is reviewing
credits received when a trip is cancelled have      The fiscal directive will be revised to                             to determine whether credits are being
to be used by the original employee/traveler        specifically address that division                                  monitored.
within one year. For FY2008, Parkland had           management is responsible to assure
credits for 20 travelers, totaling $4,858.40;       the appropriate use of credits.
expire as a result of a cancelled trip.
IAS noted that two of the credits were for
terminated employees and one was for a
prospective employee.

2009-012 Travel                                     Frank Hemeon                                10/23/2009   6/2/2010   b. Charge Review
10/27/2009                                                                                                              3. Credit Cards

2009-013 Grant Management                           Frank Hemeon                                 Status
3/23/2010                                                                                        Open                   1. Underexpended Grant Funds

For 8 of 30 grants tested (27%), departments        Grant applications include budget           3/31/2010               As of 9/30/10, IAS is selecting a sample of
utilized less than 90% of available funding.        guidance and an accompanying budget                                 grant applications completed after
Factors contributing to the underutilization        tool to identify the expenses that can be                           3/31/2010. Testwork will be performed
included delayed receipt of invoices, hiring        charged to the grant. The                                           during the first quarter of FY 2011.
delays, restrictions imposed by the grantor,        implementation of another tool appears
and overestimation of expenses. In addition,        to be a duplication of effort and would
IAS noted that for 86% (26 of 30) of the grant      create an additional requirement for
applications, departments did not seek              departments to satisfy in addition to
assistance from Grants Management to                providing the required documents by the
develop the budget.                                 grant application deadline. Grants
The following details the underutilization of the   Management will work more closely with
eight grants identified:                            departments and their Financial


                                                                                  B-19
                                                      Parkland Health & Hospital System
                                                            Internal Audit Services
                                                      Audit Follow-Up Summary Report
                                                        Fiscal 3rd & 4th Quarters 2010
                                                 All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                     Responsible Management              Target   Complete   Observation Title & Auditor Comments
               Report Date                          Original Management Response            Date      Date      and/or Follow Up Mgmt Responses


   1. Program: AETC - Ryan White F               Operations Analyst to aid in developing
                                                 the application budget.
       Amount Awarded: $1,553,167
       Expenditures Reported to Grantor:
       $1,242,211Funding Utilized: 80%
       Explanation: Waiting for two
       subcontractors to submit final invoices
       since June 2009

   2. Program: Nurse Family Partnership

       Amount Awarded: $806,284
Expenditures Reported to Grantor:
$410,145Funding Utilized: 51%
Explanation: Hiring delays
   1. Program: Project Support - Frew Pedi
       Integrated MH

       Amount Awarded:
       $484,650Expenditures Reported to
       Grantor: $144,578
       Funding Utilized: 30%Explanation:
       Hiring delays, staff vacancies, and
       insufficient documentation to bill for
       pediatrician-therapist consultations

   2. Program: Family Planning Outreach -
      Title X - Hard to Reach Populations -
      African Americans

          Amount Awarded: $450,000
Expenditures Reported to Grantor: $57,093
Funding Utilized: 13%Explanation: Shortened
grant year, hiring delays, project scope
change, and changes to the state's contract
notification process
     1. Program: MRSA Colonization &


                                                                              B-20
                                                 Parkland Health & Hospital System
                                                       Internal Audit Services
                                                 Audit Follow-Up Summary Report
                                                   Fiscal 3rd & 4th Quarters 2010
                                            All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                Responsible Management             Target     Complete    Observation Title & Auditor Comments
               Report Date                     Original Management Response           Date        Date       and/or Follow Up Mgmt Responses


       Control in the Cook County Jail

       Amount Awarded: $282,762
       Expenditures Reported to Grantor:
       $218,949Funding Utilized: 77%
       Explanation: Delayed project start

   2. Program: Ryan White Part D - Youth
      Angle

       Amount Awarded: $132,253
Expenditures Reported to Grantor:
$100,693Funding Utilized: 76%
Explanation: Project scope change
   1. Program: HOMES CHS-Federally
       Qualified Health Center

       Amount Awarded:
       $89,845Expenditures Reported to
       Grantor: $74,016
       Funding Utilized: 82%Explanation:
       Overestimated medical equipment
       expense

   2. Program: Reducing HAI

        Amount Awarded: $47,455
Expenditures Reported to Grantor: $19,692
Funding Utilized: 41%Explanation: Delayed
operating decisions by grantor




2009-013 Grant Management                   Frank Hemeon                            7/30/2010   6/22/2010   a. Application Process
3/23/2010                                                                                                   2. Indirect Costs



                                                                        B-21
                                                      Parkland Health & Hospital System
                                                            Internal Audit Services
                                                      Audit Follow-Up Summary Report
                                                        Fiscal 3rd & 4th Quarters 2010
                                                 All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                     Responsible Management               Target     Complete    Observation Title & Auditor Comments
               Report Date                          Original Management Response             Date        Date       and/or Follow Up Mgmt Responses


2009-013 Grant Management                        Frank Hemeon                             7/30/2010    6/22/2010   b. Intended Use
3/23/2010                                                                                                          2. Indirect Costs

2009-013 Grant Management                        Frank Hemeon                             Status In                a. Contracts Exceeding $200K
3/23/2010                                                                                 Progress                 3. Board Reporting

Of 25 2008-2009 grant awards exceeding           Federal grant awards do not have a       3/31/2010                As of 10/5/10, for 9 of 10 testwork items
$200,000, IAS determined that 6 (24%) were       contract to execute. A determination                              (90%), the grants were reported to and
not presented to the Board for approval.         was made that the award notices should                            approved by the Board. One grant (10%)
    1. Program: Federal Poison (Amount:          go to the Board for approval even                                 has not been reported to the Board,
        $499,502)                                though there was no contract document.                            because Grants Management has not
    2. Program: AETC - Ryan White Part F         However, some of the federal awards                               received the contract from the Department
        (Amount: $1,553,167)                     were missed during the processing of                              of State Health Services (DSHS).
    3. Program: Ryan White Part C (Amount:       the grant awards. We have made
        $851,473)                                procedural changes to ensure they
    4. Program: HOMES (Amount:                   tracked and presented to the Board, as
        $1,395,941)                              appropriate.
    5. Program: ARRA Increased Demand
        for Services (Amount: $269,861)
    6. Program: Title V - Child Health &
        Dental (Amount: $383,114; an
        amendment caused contract to
        exceed $200,000)

The omissions were due to different
interpretations of Parkland's contract
procedure (Fiscal Procedure 8311-3-12). With
the exception of Title V - Child Health &
Dental, all of the grants listed above are
federal. At one point, federal grants were not
presented to the Board because there was no
contract to sign. There have also been various
interpretations as to whether amendments
causing contracts to exceed $200,000 should
go to the Board.

2009-209 Bed Tracking                            Walter Jones                             11/15/2009   7/3/2010    4. Operational Efficiencies
9/22/2009                                                                                                          4. Operational Efficiencies


                                                                             B-22
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                    Target    Complete    Observation Title & Auditor Comments
                Report Date                           Original Management Response                  Date       Date       and/or Follow Up Mgmt Responses


2010-005 Engineering Services                      Walter Jones                                   Status                a. Authorized Drivers
8/24/2010                                                                                         Open                  1. Hospital Owned Vehicles

According to Fiscal Policy 8311-3-05 (Motor        Engineering department will maintain an        8/3/2010              Testing will be performed in the first quarter
Vehicles), each Department Director who            update approved drivers list. This list will                         of Fiscal Year 2011.
manages the use of a Parkland owned vehicle        be updated and audited by the
is to provide a list of all employees authorized   Engineering Management team a
to drive that vehicle to the Department of         minimum of twice a year and revised as
Legal Affairs. However, the current process is     needed. Parkland Hospital Police
such that when an employee is requested to         Department will complete DMV checks
be added to the authorized drivers list, Human     on all approved drivers.
Resources (HR) processes the driving record
with Group One. Once it is clear, HR notifies
the Department. Legal Affairs is not notified.
To determine if hospital owned vehicles are
being properly utilized by authorized
individuals, IAS randomly selected 30
individuals from the Engineering vehicle sign-
out logs for October 2009 through March 2010
and verified they appeared on Engineering's
authorized drivers list. IAS noted five of 30
(17%) employees did not appear on
Engineering's authorized drivers list. However,
these five employees did appear on the
authorized driver list provided by Human
Resources. Three of the five drivers are
employed by Clinical Engineering, but operate
Engineering vehicles periodically. One
employee is no longer with Parkland. One
employee is an offsite COPC Engineering
employee.
In addition, IAS randomly selected 30
employees from the authorized drivers list
kept by Engineering and had the Parkland
Police verify their driving records. At the time
of the review, two of 30 (7%) Engineering
employees who appear on the Engineering
authorized driver list did not have a valid


                                                                                   B-23
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management               Target     Complete    Observation Title & Auditor Comments
               Report Date                           Original Management Response             Date        Date       and/or Follow Up Mgmt Responses


Texas Driver’s License. One of the two
employees did not appear on the authorized
driver list provided by Human Resources.
Both employee job descriptions require a valid
Texas Class C Driver License, and to be
insurable. The vehicle sign out logs for FY
2010 do not indicate that either of the two
employees operated a vehicle in FY 2010.
Parkland Police verified the driving records of
drivers hospital wide and identified two
additional employees that did not have a valid
drivers license. These two employees are not
employed by Engineering.


2010-005 Engineering Services                     Walter Jones                               Status                b. Vehicle Maintenance
8/24/2010                                                                                    Open                  1. Hospital Owned Vehicles

Engineering procedure Hospital Owned              The approved vehicle safety inspection    8/13/2010              Testing will be performed in the first quarter
Vehicles 8071-03-09, requires weekly vehicle      is now assigned to designated                                    of Fiscal Year 2011.
safety inspections and all vehicles should        personnel and these personnel shall
receive regular scheduled maintenance. IAS        receive training on expectations and
reviewed the vehicle safety inspection records    consistent documentation practices.
for all eight vehicles for January 2010 through   Designee and training will be completed
March 2010. All eight vehicles had current        by 8/13/2010.
safety inspections. However, the Engineering      The Engineering Department will
staff is inconsistent in completing the vehicle   attempt to get any and all
safety inspection sheet.                          documentation related to Parkland
Additionally, all vehicles receive regularly      Engineering Hospital vehicle repairs
scheduled maintenance at the Dallas County        completed by Dallas County. Effective
Automotive Repair Center based on a               8/3/2010.
maintenance schedule; however, Engineering
does not track and document the preventative
maintenance on the vehicles.

2010-005 Engineering Services                     Walter Jones                               Status                Monthly Inspections
8/24/2010                                                                                    Open                  4. Quality Assurance Inspections



                                                                               B-24
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                     Responsible Management               Target     Complete     Observation Title & Auditor Comments
                Report Date                          Original Management Response             Date        Date        and/or Follow Up Mgmt Responses


According to the Engineering Services             Work Order Policy has been updated to     8/11/2010               Testing will be performed in the first quarter
procedure Quality Assurance Inspections           have all shops QA 20 work orders per                              of Fiscal Year 2011.
8071-03-18, each Engineering Service shop         month per trade. This is more
should inspect a minimum of 10% of the            achievable and real approach to monitor
monthly work orders issued to their shop(s).      the program.
During this supervisory inspection, a quality
rating should be recorded on the work order
form. IAS verified 10% of each shops
assigned work orders were inspected for
January 2010 to March 2010. The following
was noted;
     1. Engineering shops are not
         consistently performing inspections of
         10% of the monthly work orders
         assigned.
     2. Supervisors are not consistently
         providing a quality rating.
     3. Supervisor signatures were not
         legible.


2010-005 Engineering Services                     Walter Jones                               Status                 Policy and Procedures
8/24/2010                                                                                    Open                   5. Policy and Procedures

The current Engineering Services Policy and       Work Order Policy has been updated to     8/11/2010               Testing will be performed in the first quarter
Procedure Manual (revised December 2008)          have all shops QA 20 work orders per                              of Fiscal Year 2011.
does not reflect current practices. Since the     month per trade. This is more
last revision of the manual there have been       achievable and real approach to monitor
changes in management and in the                  the program.
maintenance management system used by
Engineering.

2008-018 Payroll                                  Candy Knowles                             9/30/2009   10/6/2010
2/24/2009                                                                                                           2. Payroll Accuracy

2008-203 Ingenix Coding EPIC Abstracting          Jack Kowitt                                 Risk      6/15/2010   Visible Source Code
8/26/2008                                                                                   accepted                2.Visible Source Code



                                                                               B-25
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                  Target     Complete     Observation Title & Auditor Comments
                Report Date                           Original Management Response                Date        Date        and/or Follow Up Mgmt Responses


IAS noted that the users could easily view the     IT has contacted the vendor and they        9/30/2009    6/15/2010   Management accepts the risk.
source code of the WebPages generated by           are looking into this request. The vendor
the application. Some of these pages contain       will engage Development as their                                     Follow Up Management Response:
Java Scripts that enables interaction by the       Service and Implementations                                          The vendor stated that they had no
user. Programming to hide sensitive code is        departments cannot address this issue.                               immediate plans in the future to do this. We
not used in the application for reducing                                                                                consider the risk very small.
potential web attacks..

2009-004 Pharmacy Administration                   Jack Kowitt                                 12/14/2007   6/30/2010
6/13/2007                                                                                                               3. Medication Overcharges

2009-014 Garland Health Center                     Jack Kowitt                                 1/19/2010    5/24/2010   b. Technical Charges
12/8/2009                                                                                                               1. Charge Capture

2009-014 Garland Health Center                     Jack Kowitt                                   Risk       9/16/2010   Lab Results
12/8/2009                                                                                      accepted                 7. Lab Orders

In Epic, the order status is not being updated     After thorough review of this issue, IT     3/31/2010    9/16/2010   Management accepts the risk.
on the parent order for the Complete Blood         has determined that Cerner will need to
Count with differential test. Since February 17,   provide changes to their interface in                                Follow Up Management Response:
2009, there were 752 Garland lab                   order to more appropriately link the CBC                             At this time, there is no software solution
appointments showing "No Results" for the          parent/child components (currently the                               planned for this issue. As Cerner / Epic
CBC with differential test on the lab visit in     children tests are being populated and                               change their software, Lab and IT will
report reviewer. However, in the results           updated and the parent order is                                      continue to look for changes that can be
reviewer there are lab results for the visit.      orphaned). We have contracted with                                   applied to fix this low-risk situation.
Health care providers, as well as others, rely     Cerner for this work and they will
on data displayed in Epic. Inconsistent            provide interface code changes such
information is being displayed on different        that the parent order will be matched
screens in Epic.                                   with the child status and results. We
                                                   plan on a go live with the re-worked
                                                   interface code by the end of March,
                                                   2010.



2009-015 Respiratory Care                          Jack Kowitt                                 Status In
3/23/2010                                                                                      Progress                 3. Compliance with Standards



                                                                                 B-26
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management                 Target     Complete    Observation Title & Auditor Comments
               Report Date                           Original Management Response               Date        Date       and/or Follow Up Mgmt Responses


IAS review of Clinivision indicated the           The Clinivision system is an older          9/30/2010              Requested the copies of the risk
following deficiencies with regard to             system and is not capable of                                       acknowledgements on 9/29/10.
compliance with HIPAA and Information             maintaining an audit trail. In accordance
Security Standards:                               with PHHS Information Security
     1. The audit trails in Clinivision are not   Standards, a Risk Acknowledgment was
        monitored as required by HIPAA            obtained from department leadership
        standards and implementation              requiring them to develop and abide by
        specifications because the system         a procedure to use as a compensating
        lacks adequate tools for monitoring.      control for such lack of a log. A similar
     2. Clinivision uses PC Anywhere for          Risk Acknowledgment was signed and
        access between Clinivision and            compensating control developed
        Cloverleaf (Interface). Although PC       covering the use of PCAnywhere as the
        Anywhere is properly installed            interface tool for this system.
        according to PHHS Information
        Security Standards, Respiratory Care
        has not obtained the authorized risk
        waiver from Information Security as
        required by the standards. The waiver
        ensures that the scope of the
        connectivity application is approved
        by the Information Security
        Department.
     3. Respiratory Care Department, who is
        responsible for the system
        administration including security does
        not have documented administration
        procedures.
     4. The password management for
        Clinivision were not in compliance
        with PHHS Information Security
        Standards. During the course of the
        audit changes were made to the
        security configuration to ensure
        compliance.


2009-015 Respiratory Care                         Jack Kowitt                                  Status
3/23/2010                                                                                      Open                  4. Clinivision Contract


                                                                                B-27
                                                      Parkland Health & Hospital System
                                                            Internal Audit Services
                                                      Audit Follow-Up Summary Report
                                                        Fiscal 3rd & 4th Quarters 2010
                                                 All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                     Responsible Management                   Target     Complete     Observation Title & Auditor Comments
               Report Date                          Original Management Response                 Date        Date        and/or Follow Up Mgmt Responses


Parkland's copy of the contract with Puritan     All payments for maintenance and             4/30/2010                IAS has not received a copy of the current
Bennet (Nellcor) shows that the contract had     support are up to date and run through                                contract. Upside (Contract Management
expired in October 2007. IAS has learned         6/30/10. Ownership of Cliniivision has                                System) also does not have a current
from the OCIO that ownership of the firm had     changed hands several times since we                                  contract for Clinivision. According to OCIO
changed hands several times and the last         originally contracted with them.                                      records, the only contract they have is the
payment for support services, made to            Maintenance payments are now made                                     one expired in 2007.
Mallinckrodt, Inc. covers a period ending June   out to Mailincrodt. IT is obtaining a copy
2009. Respiratory Care did not have any          of the current contract and will reconcile
additional information because the payments      it to the number of devices in use. Any
and authorizations are made by the OCIO.         excess paid to the supplier will be
IAS also noted that the terms of the old         recouped.
contract such as the number of annual
support for hand-held devices were higher
than actual number of devices used by the
Respiratory Care Department.

2009-208 Radiant                                 Jack Kowitt                                    Risk       6/16/2010
9/22/2009                                                                                     accepted                 05. Consistency in Field Formats

IAS noted the following inconsistencies in the   Jack Kowitt (9/5/09)                         11/30/2009   6/16/2010   Follow Up Management Response:
field display format for a few fields in         Diagnostic Imaging and Informatics will                               Diagnostic Imaging and Informatics
Radiology Image charts. On the same screen,      perform an evaluation of date and time                                evaluated the date and time stamps in the
a user could encounter:                          stamps in EPIC Radiant by September                                   Radiology Charts. These fields were
     1. Dates in different formats.              30, 2009. We will classify these fields                               classified into 3 categories; fixed formats
     2. Time in different formats.               into 3 categories; fixed formats due to                               due to interfaces; fixed formats due to Epic
     3. Provider names in different formats.     interfaces; fixed formats due to Epic                                 internal controls and Radiant
                                                 internal controls and Radiant                                         controlled/configurable. The standard is
        This slows down the user and can         controlled/configurable. For those that                               mm/dd/yyyy for date and time is presented
        cause unnecessary frustration.           are Radiant controlled/configurable, we                               in a military time format. This standard is to
        According to the Information             will then develop a mitigation plan to                                be used where appropriate and possible in
        Technology department, this is           provide consistency in these field                                    order to achieve consistency within the
        because the data comes from many         formats. Targeted Completion Date:                                    module. Below is the documentation of our
        different sources.                       11/30/09                                                              review. An analysis performed by
                                                 Diagnostic Imaging and Informatics will                               Diagnostic Imaging and Informatics of the
                                                 perform an evaluation of Provider Name                                five Radiant work spaces was made to
                                                 displays throughout the Epic Imaging                                  determine current date and time format.
                                                 Reports. We will classify these fields                                After the review, it was determined that
                                                 into 3 categories; fixed formats due to                               there were all fields within the Radiant


                                                                                B-28
                                               Parkland Health & Hospital System
                                                     Internal Audit Services
                                               Audit Follow-Up Summary Report
                                                 Fiscal 3rd & 4th Quarters 2010
                                          All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation              Responsible Management                Target     Complete    Observation Title & Auditor Comments
               Report Date                   Original Management Response              Date        Date       and/or Follow Up Mgmt Responses


                                          interfaces; fixed formats due to EPIC                              controlled workspaces are compliant with
                                          internal controls and Radiant                                      the standard.
                                          controlled/configurable. For those that                            The Diagnostic Imaging and Informatics
                                          are Radiant controlled/configurable, we                            team evaluated the name and credential
                                          will then develop a mitigation plan to                             display format in the Radiology Charts.
                                          provide consistency in these field                                 These fields were classified into 3
                                          formats.                                                           categories; fixed formats due to interfaces;
                                          Targeted Completion Date: 11/30/09                                 fixed formats due to Epic internal controls
                                                                                                             and Radiant controlled/configurable. The
                                                                                                             standard format is first name, last name,
                                                                                                             followed by credential (John M. Smith MD).
                                                                                                             This standard is to be utilized where
                                                                                                             appropriate and possible in order to
                                                                                                             achieve consistency within the system. The
                                                                                                             review found that two fields do not meet
                                                                                                             the standard display, the Result Note and
                                                                                                             the Radiant HTML order detail. Work is
                                                                                                             underway to correct program code to
                                                                                                             correct the problem.
                                                                                                             Completion Date: April 30, 2010
                                                                                                             Other occurrences that do not meet our
                                                                                                             standard are under the control of other
                                                                                                             systems and would require vendor level
                                                                                                             changes. AS this is a “Low” risk item, we
                                                                                                             might make such requests, but it would be
                                                                                                             up to the vendor to effect the change,
                                                                                                             We suggest a disposition of Closed for this
                                                                                                             item.

2009-211 ANSOS                            Jack Kowitt                               2/15/2010    7/16/2010   a. Employment start, transfer, or
1/26/2010                                                                                                    terminate date report
                                                                                                             1. PeopleSoft to ANSOS Interface

2009-007 Conflict of Interest             Nancy Merritt                             11/30/2009   7/8/2010    Pharmacy and Therapeutic Committee
6/19/2009                                                                                                    Minutes
                                                                                                             5. Committee Minutes Review

2008-005 Purchasing General Procurement   Andrew Montgomery                          6/1/2008    5/26/2010


                                                                       B-29
                                                         Parkland Health & Hospital System
                                                               Internal Audit Services
                                                         Audit Follow-Up Summary Report
                                                           Fiscal 3rd & 4th Quarters 2010
                                                    All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                       Responsible Management             Target     Complete   Observation Title & Auditor Comments
                Report Date                            Original Management Response           Date        Date      and/or Follow Up Mgmt Responses


1/22/2008                                                                                                          2. Verifying W/MBE Participation

2008-015 Fixed Asset and General Ledger             Andrew Montgomery                        Status
11/19/2008                                                                                   Open                  1. Reconciling Trackable Assets

When trackable assets bypass the receiving          Processes will be developed to insure   6/30/2009              MRD is working on a process to address
dock, no reconciliation process exists to           that assets are appropriately tagged    6/30/2010              the issue.
ensure that the assets are tagged. Upon             and also to account for transfers
issuance of a purchase order, the Materials         between departments.
Resources Department (MRD) assigns a tag
number. MRD physically affixes tags to
trackable assets that are delivered through the
receiving dock. If the asset goes directly to the
department that requested it, the tag stays in
MRD.
1. Of 29 trackable assets located by IAS
     during fieldwork, none had tags affixed to
     them.
2. One of 30 trackable assets tested (3%)
     was not in its assigned location. A $920
     fax machine purchased in May 2008 was
     assigned to Medicine Services
     Administration (MSA), but IAS did not find
     it there. MSA stated that it gave the fax
     machine to 8 North, but 8 North did not
     have it either. IAS did not locate the fax
     machine during the audit.
Fiscal Manual Procedure 8311-5-09, "Property
and Equipment Control," states that the Vice
President of Strategic Sourcing is responsible
for overseeing the non-capital asset tracking
process. In Fiscal Year 2008, Parkland
purchased $1,932,776.02 of assets under
$5,000.

2008-212 PYXIS                                      Andrew Montgomery                       5/29/2009   7/2/2010   c. PYXIS SUPPLYSTATION (null)
11/19/2008                                                                                                         transactions
                                                                                                                   2. Data Integrity


                                                                                 B-30
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management                Target     Complete     Observation Title & Auditor Comments
               Report Date                           Original Management Response              Date        Date        and/or Follow Up Mgmt Responses


2009-005 Contract Labor                           Andrew Montgomery                         10/31/2009   5/14/2010   Invoice rates
6/19/2009                                                                                                            5. Financial Analysis

2009-006 Equipment Rental                         Andrew Montgomery                          5/1/2010    8/5/2010    a. Equipment Tracking
9/22/2009                                                                                                            1. Equipment Tracking and Invoice
                                                                                                                     Reconciliation

2009-006 Equipment Rental                         Andrew Montgomery                          9/4/2009    4/2/2010
9/22/2009                                                                                                            3. Record Retention

2009-007 Conflict of Interest                     Andrew Montgomery                         6/30/2009    9/29/2010   a. Pharmacy and Therapeutic/Value
6/19/2009                                                                                                            Analysis Disclosures
                                                                                                                     4. Purchasing Decisions

2009-007 Conflict of Interest                     Andrew Montgomery                         6/11/2009    5/14/2010   b. Request for Proposal Files- Missing
6/19/2009                                                                                                            documentation
                                                                                                                     4. Purchasing Decisions

2009-007 Conflict of Interest                     Andrew Montgomery                         11/30/2009   7/8/2010    Pharmacy and Therapeutic Committee
6/19/2009                                                                                                            Minutes
                                                                                                                     5. Committee Minutes Review

2010-004 Post Partum                              Andrew Montgomery                          Status                  a. Charge Capture
8/24/2010                                                                                    Open                    1. Supply Charge Capture

Post Partum patient care staff are responsible    Agree. All charges received by MRD will   6/21/2010                IAS will test first quarter of Fiscal Year
for tracking supplies used in each patient's      be entered accurately into Epic.                                   2011 to validate accuracy.
care by putting an inventory sticker and a date
of service on each patient's daily charge
sheets. Material Services then picks up the
charge sheets from the units and ensures that
all charges are entered accurately into Epic.
Approximately $42,000 in supply charges are
entered for Post Partum monthly.
IAS randomly selected and tested 30 Post
Partum patients and reviewed their supply
charges for accuracy and identified the
following:
     1. 4 of 30 (13%) charges could not be

                                                                               B-31
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

         Audit No./Name & Observation                   Responsible Management                 Target    Complete    Observation Title & Auditor Comments
                  Report Date                        Original Management Response               Date       Date       and/or Follow Up Mgmt Responses


          reconciled because charge sheets
          could not be located by Material
          Services.
    2.    For 25 of the remaining 26 (96%)
          charge sheets, the service date did
          not match the date in EPIC.
    3.    1 of 26 (3%) charge sheets entered in
          EPIC were allocated to the incorrect
          cost center.
    4.    1 of 26 (3%) charge sheets do not
          match charges in EPIC.
    5.    1 of 26 (3%) charge sheets was not
          entered into EPIC.
    6.    1 of 26 (3%) charge sheets did not
          have a service date completed by the
          Post Partum patient care staff.

2010-004 Post Partum                              Andrew Montgomery                           Status                 b. Charge Entry
8/24/2010                                                                                     Open                   1. Supply Charge Capture

During IAS review of the supply charge            Agree. Material Services will provide all   7/1/2010               IAS will test once training is completed and
sheets, IAS observed the following:               necessary training to insure charges are                           allow time for transactions to be processed
    1. The clerk entering charges was using       entered accurately. The procedure has                              after training.
        another employee's user ID and            been updated to reflect current
        password to access Epic. According        processes and no user ID's will be
        to the Information Security Standards,    shared.
        employees are not to share user ID's
        and passwords.
    2. The clerk had not received EPIC
        training.
    3. No training manual specific to the
        Material Services process on entering
        supply charges is available.


2008-017 COPC Administration                      Sharon Phillips                             2/9/2007   7/12/2010
10/28/2008                                                                                                           5. MBI Audits



                                                                                B-32
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management               Target     Complete    Observation Title & Auditor Comments
               Report Date                           Original Management Response             Date        Date       and/or Follow Up Mgmt Responses


2009-014 Garland Health Center                    Sharon Phillips                           1/19/2010   5/24/2010   b. Technical Charges
12/8/2009                                                                                                           1. Charge Capture

2009-303 Collecting Medicare CoInsurance          Sharon Phillips                           9/30/2009   4/29/2010   1. Review of Charity Bad Debt Accounts
Deductibles                                                                                                         1. Review of Charity Bad Debt Accounts
5/26/2009

2010-002 Radiology Administration                 Richard Rhine                             Status In               b. National Breast Cancer Foundation
5/25/2010                                                                                   Progress                6. Grants

NBCF requires that the patient have an            PFS began staffing a Financial            5/12/2010               IAS selected a sample of 10 patients who
income below 200% of the Federal poverty          Counselor in the mobile unit on                                   were placed on the National Breast Cancer
level and have no medical insurance or have       04/15/10 to assure that NBCF patients                             Foundation (NBCF) grant in July and seven
a co-pay that makes it difficult for them to      represent the PHP population. This will                           of 10 (70%) patients did not have PHP
access care. IAS requested supporting             assure compliance with the 200% FPL                               coverage at the time they were placed on
documentation showing the financial status for    requirement.                                                      the NBCF grant.
patients receiving grant funding. IAS noted
Financial Counselors do not verify the                                                                              Follow Up Management Response:
patient's ability to pay prior to adding grant                                                                      The overall process of screening patients
funding to the account. A verbal declaration is                                                                     for the NBCF grant will change in order to
accepted.                                                                                                           assist as many patients as possible to
                                                                                                                    receive mammography services. PFS has
                                                                                                                    financial counselors at the Breast Center
                                                                                                                    as well as the Mobile unit. Since the patient
                                                                                                                    often does not have the necessary
                                                                                                                    paperwork to complete the PHP application
                                                                                                                    process, the FC will check EPIC to insure
                                                                                                                    the patient is covered by an entity which
                                                                                                                    requires the patient to be under 200% of
                                                                                                                    the FPIL. This would include PHP, BCCS,
                                                                                                                    Title V, Tax Support and CHIP. If the
                                                                                                                    patient is not currently enrolled in one of
                                                                                                                    these programs, the FC will utilize Search
                                                                                                                    America to determine the patient's FPIL.
                                                                                                                    These steps will better serve the patient
                                                                                                                    and reduce risk of providing grant funding
                                                                                                                    to unqualified individuals.



                                                                                B-33
                                                          Parkland Health & Hospital System
                                                                Internal Audit Services
                                                          Audit Follow-Up Summary Report
                                                            Fiscal 3rd & 4th Quarters 2010
                                                     All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                        Responsible Management                  Target     Complete     Observation Title & Auditor Comments
                Report Date                             Original Management Response                Date        Date        and/or Follow Up Mgmt Responses


2010-002 Radiology Administration                    Richard Rhine                                5/12/2010   9/28/2010   c. Susan Komen
5/25/2010                                                                                                                 6. Grants

2009-304 APC                                         John Shannon                                  Status
7/28/2009                                                                                          Open                   2. Physician Documentation

Not all physician dictated reports were clear        John Shannon, M.D. (7/7/09)                  3/30/2010               Met with a Nursing Informatics Specialist
as to the spinal levels treated.                     I have sent a written recommendation         10/8/2010               on 10/11/10 who demonstrated the EMR
29 of the 45 accounts reviewed or 64% the            on June 5, 2009 to the Medical Director                              "smart phrase" now used by providers of
documentation of the specific spinal levels          of Pain Services for Parkland and the                                facet joint injection procedures for
was not clear. Facet joint injection coding can      Director of Coding & Registry of HIM                                 documenting the procedures. IAS will
be difficult due to differing terminology relating   requesting that the Pain Services                                    obtain a sample of 10 facet joint injection
to the paravertebral spinal anatomy and the          Medical Director instruct his providers of                           procedures performed subsequent to the
approach techniques. The following are all the       the necessity for clear description of                               EMR go-live in the Pain Management
factors that a coder needs to consider when          injection sites, including specificity of                            Clinic and retest to determine if the EMR
assigning the appropriate code and the               which vertebral interspace was injected                              provides more specificity in the
documentation needs to be clear :                    and whether left, right or bilateral                                 documentation of these procedures.
Injection(s) targeted the paravertebral facet        injections were performed; and the
joints at one or both sides at a given spinal        therapy given, whether a drug was
level                                                injected, radio-frequency applied, or
The facet injection(s) occurred at a single or       both.
multiple vertebral level(s)                          Targeted Completion Date:
Injections were performed at differing spinal        Completed
regions (e.g., cervical/thoracic or lumbar)          We plan for the Epic outpatient clinical
The injection(s) were performed within the           documentation build for the Pain Clinic
facet joint(s) or over facet joint nerve(s)          to include this same specificity into the
The injection(s) were performed unilaterally or      EMR.
bilaterally at a given level                         Targeted Completion Date:March 30,
Examples of documentation that are not clear         2010
to the levels treated:
Account number 604855889 –
Pre and Post Diagnosis “Lumbar spondylosis”
(no level indicated) Name of Operation:
Bilateral diagnostic median branch block from
L3 to S1 on both sides. Coder reported 3
spinal levels were treated.
Does L3 mean L2-L3? Or L3- L4?
In the body of the operative report


                                                                                    B-34
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                  Target     Complete   Observation Title & Auditor Comments
                Report Date                           Original Management Response                Date        Date      and/or Follow Up Mgmt Responses


documentation stated that L2 was injected as
well as L3, L4, L5, and S1. Coder did not pick
up the L2-L3 level. After review, 4 spinal
levels were treated.
Examples of good documentation:
Pre and Post Diagnosis “Left L4-L5 intra-
articular facet diseaseName of Operation: Left
L4-L5 and L5-S1 intra-articular facet injection.
In the body of the report documentation clear.
Findings: Needle placement in the L4-L5 and
L5-S1 facet joints.

2008-307 DRG                                       John Shannon, Shelly Monks                   Status                 a. Attending
9/23/2008                                                                                       Open                   5. Provider Assignment

Nine of 60 (15%) accounts reviewed have an         A Physician Attribution workgroup has       12/31/2008              Shelly Monks provided an update on
incorrectly assigned attending provider. Per       been established. The workgroup is                                  9/30/10 on Physician Attribution workgroup
HIM Coding Management, the assignment of           chaired by Dr. Jay Shannon. Members                                 activity in regards to attending physician
the attending provider is based on the             include: Drs. Ruben Amarasingham,                                   assignment. She also provided HIM IP, OP
provider who signs the discharge summary.          Brian Casey, Tony Dal Nogare, Heidi                                 and COPC abstracting procedures. IAS in
Coding procedures provided do not provide          Frankel, Joe Minei, Angelique Ramirez                               the process of reviewing and clarifying the
guidance on attending provider assignment.         and Gary Reed; Kim Akinwande; Shelly                                procedures with Shelly and Lenore Whalen
                                                   Monks; and Robin Stults. To date, the                               in HIM.
                                                   workgroup has met on two occasions,
                                                   June 16, 2008 and July 31, 2008.
                                                   Targeted completion Date: A plan to
                                                   address the assignment of the attending
                                                   physician will be developed by
                                                   December 31, 2008.

2008-014 Trauma Department                         Brad Simmons                                 Status                 Chart Documentation
11/19/2008                                                                                      Open                   1.Medical Record Documentation/Charge
                                                                                                                       Capture

IAS randomly selected a sample of 30               The Trauma Mid Level Provider               12/1/2008               There has been no update to the process.
accounts and reviewed billing claims, medical      assisting in the discharge of the patient                           Jay Shannon is responsible.
records, and EPIC to determine if the correct      will define for the unit HUC the correct
attending physician was documented and if          provider.


                                                                                  B-35
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management                  Target     Complete   Observation Title & Auditor Comments
               Report Date                           Original Management Response                Date        Date      and/or Follow Up Mgmt Responses


EPIC charges agreed with the claim.               Trauma Services will work with the
In 15 of 30 (50%) accounts the attending          inpatient units to ensure this issue is
physician in EPIC and the discharging             addressed.
provider in the medical record did not agree.
In addition, five of the same 15 accounts had
the incorrect provider appear on the claim.

2008-014 Trauma Department                        Brad Simmons                                  Status                Regulations for Trauma Activation
11/19/2008                                                                                      Open                  2.Medical Record Documentation

The Centers for Medicare (CMS) Manual 100-        This process is in place.                    5/19/2009              IAS reviewed a random sample of 10
04, Chapter 25, Section 75.4, effective           Trauma Services and Government                                      accounts with a trauma activation charge.
January 1, 2007 says that evidence of             Reimbursement have addressed this                                   The DOS of these accounts ranged from
documentation in the medical record that a        issue. There are currently charges that                             January - February 2010. Of these, IAS
"Notification of key hospital personnel in        define pre-hospital notification and                                noted the following:
response to triage information from pre-          charges that define no pre-hospital                                      1. 3 of 10 (30%) accounts had
hospital caregivers in advance of the patient's   notification. Those that have no pre-                                          documentation of pre-hospital
arrival." must be present to bill a trauma        hospital notification receive a $0 charge.                                     notification to support the trauma
activation charge.                                                                                                               activation charge.
During the time of the review IAS found that                                                                               2. 7 of 10 (70%) accounts did not
Trauma Activation charges were applied to all                                                                                    have documentation of pre-hospital
accounts including the accounts that the                                                                                         notification to support the trauma
hospital did not receive notification of the                                                                                     activation charge.
patients arrival as a trauma case.                                                                                    Management has responded to this issue
IAS selected a sample of 10 accounts with a                                                                           by implementing charges that define pre-
Trauma Activation charge.                                                                                             hospital notification and charges that define
IAS noted that in 8 of 10 (80%) the medical                                                                           no pre-hospital notification. However there
records did not contain documentation of a                                                                            is still an issue with the documentation to
prehospital notification from a prehospital                                                                           support a trauma activation charge.
caregiver.                                                                                                            IAS and the Trauma Registry team are
The Director of Trauma Management is aware                                                                            currently looking into this issue.
of the CMS regulation and is working with the
Government Reimbursement Department to
correct the process.

2008-014 Trauma Department                        Brad Simmons                                 Status In              b. Time and Date Stamp
11/19/2008                                                                                     Progress               3.Trauma Registry



                                                                                  B-36
                                                          Parkland Health & Hospital System
                                                                Internal Audit Services
                                                          Audit Follow-Up Summary Report
                                                            Fiscal 3rd & 4th Quarters 2010
                                                     All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                        Responsible Management                 Target     Complete   Observation Title & Auditor Comments
                Report Date                             Original Management Response               Date        Date      and/or Follow Up Mgmt Responses


According to the Trauma Program Procedure            The Trauma Registry Manager has              1/1/2009              Targeted completion has been revised to
Manual initial data is entered into the trauma       contacted the Registry Software Vendor      2/28/2011              February 2011.
database (TRACS) within forty eight hours of         regarding the entry time and date auto
admission. IAS randomly selected 10 patients         stamp.
who were entered into the Registry according
to the inclusion criteria. Registry entries do not
capture the date and time. This functionality is
available but not in use.

2008-021 ASC                                         Brad Simmons                                Status In              Timely Completion of History and
1/14/2009                                                                                        Progress               Physical
                                                                                                                        1. History and Physical Examination

While reviewing a sample of charts for timely        Effective January 12, 2009, Ambulatory      2/1/2009               IAS reviewed 10 ASC charts. As of
completion of the history and physical (H&P)         Surgery Center/OR Pre-op staff will         4/1/2010               10/8/10, for 1 of 10 patients tested (10%),
examination, IAS noted the following:                confirm the presence and completion of                             IAS found no evidence that the provider
ASC:                                                 the history and physical form on the day                           reviewed the history & physical and
    1. For eighteen of 40 (45%) charts, the          of surgery. The Pre-op staff will confirm                          documented whether anything had
        provider did not record the date and         that the H&P is on the chart for the                               changed.
        time that the prior H&P was reviewed.        respective patient, that the H&P is no
    2. Five of 40 (13%) charts had a stamp           greater than 30 days old, and that the
        indicating that the H&P had been             H&P has been reviewed (stamped),
        reviewed and there were no changes,          dated and signed by the responsible
        but the provider did not initial the         physician before releasing the patient to
        stamp.                                       be taken to the OR. The Circulator
    3. Four of 40 (10%) charts had no stamp          assigned to the case will also perform a
        or notes indicating that nothing had         check of the patient’s chart to confirm
        changed since the patient's last H&P.        the presence of a valid H&P before
    4. One of 40 (3%) charts had no H&P              transporting the patient to the OR. The
        documentation.                               staff has been instructed to delay the
    5. One of 40 (3%) charts had no                  surgical procedure until the H&P
        documentation for the surgery date.          documentation is complete. The only
    6. One of 40 (3%) charts indicated that          exception will be the emergent cases
        the patient's H&P was completed              admitted through the main OR.
        more than 30 days prior to surgery.          An informational campaign for
OR:                                                  physicians which includes the
    1. Four of 38 (11%) charts had a stamp           requirement for signature, date, and
        indicating that the H&P had been             time on all entries is being designed and


                                                                                   B-37
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                     Responsible Management                   Target     Complete   Observation Title & Auditor Comments
                Report Date                          Original Management Response                 Date        Date      and/or Follow Up Mgmt Responses


         reviewed and there were no changes,      will be presented at the January OR
         but the provider did not initial the     committee. With anticipated approval,
         stamp.                                   this campaign will be rolled out January
     2. Three of 38 (8%) charts indicated that    20, 2009.
         the patient's H&P was completed          A review of the Pre-operative checklist
         more than 30 days prior to surgery.      is being conducted by the OR Educator,
     3. Two of 38 (5%) charts had no stamp        Carissa Little. Any changes to the
         or notes indicating that nothing had     current form will be completed by
         changed since the patient's last H&P.    February 28, 2009. This will also include
     4. For 2 of 38 (5%) charts, the provider     an education plan for identified
         did not record the date and time that    changes, revision of current policy and
         the prior H&P was reviewed.              inclusion in the audit tool. Unit
According to Medicare Conditions of               Managers of the Pre-op units and the
Participation for Surgical Services, medical      ORs will perform monthly audits of
history and physical examinations must be         overall compliance. Results of the audit
completed and documented no more than 30          will be posted in the Operative Suite and
days before or 24 hours after admission or        ASC respectively.
registration. Updated examinations of the         The audit tool is being finalized and will
patient, including any changes in the patient's   be available for February 1, 2009.
condition, must be completed and
documented within 24 hours after admission
or registration when the medical history and
physical examination was completed within 30
days before admission or registration.

2008-021 ASC                                      Brad Simmons                                 Status In               Consent Documentation
1/14/2009                                                                                      Progress                2. Consent for Procedures

According to Medicare Conditions of               Effective January 12, 2009, Ambulatory        2/1/2009               IAS tested a random sample of 20 (10 ASC
Participation for Surgical Services a properly    Surgery Center/OR Pre-op staff will          11/30/2009              and 10 OR) patients who received surgery
executed informed consent form for the            confirm the presence of consent for care                             in August and September to determine if
operation must be in the patient's chart before   and treatment (informed consent for                                  the Consents for Anesthesia and Sedation
surgery, except in emergencies. Consent for       operative procedure) and that this form                              were documented correctly and in entirety.
Surgery and applicable procedures shall be        is complete (initialed by patient and                                IAS noted that in seven of 20 (35%)
obtained by the Responsible Provider. A           signed by all applicable parties).                                   procedures Consents for Anesthesia and
separate consent form is obtained by an           Ambulatory Surgery Center/OR                                         Sedation were not completed correctly
Anesthesia Provider for all procedures            circulators (OR nurses) assigned to the                              and/or in entirety.
requiring any form of anesthesia. IAS tested a    cases will confirm the presence of a


                                                                                 B-38
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                Target   Complete   Observation Title & Auditor Comments
                Report Date                           Original Management Response              Date      Date      and/or Follow Up Mgmt Responses


random sample of 40 records for ASC and 34         valid operative consent and anesthesia
for OR to determine if proper consent for          consent prior to transporting the patient
procedures were documented. IAS noted the          to the operating room.
following:                                         OR nursing staff has been instructed to
ASC:                                               delay the surgical procedure until all
     1. One of 40 (3%) records did not             consents are present with all required
         contain a Consent for Anesthesia and      detail on all non-emergent cases.
         Sedation. 33 of 39 (85%) Consents for     An informational campaign for
         Anesthesia and Sedation were not          physicians and Anesthesia providers
         completed in entirety and/or correctly.   which includes the requirement for
     2. One of 40 (3%) Consent for                 signature, date, and time on all entries
         Procedures did not contain a witness      is being designed and will be presented
         signature. One of 39 (3%) Consent for     at the January OR committee. With
         Anesthesia did not contain a witness      anticipated approval, this campaign will
         signature.                                be rolled out January 20, 2009. A
     3. One of 40 (3%) records did not             monthly audit of overall compliance will
         contain a consent for care and            be posted in the Operative Suite and
         treatment.                                ASC respectively for both surgical and
                                                   anesthesia consents.
OR:                                                Targeted Completion Date: Nursing staff
Three of 38 (8%) cases were considered dire        will be educated at the January 28,
medical emergency and no Consent for               2009 staff meeting to include the
Anesthesia, medical treatment, or signature        consent to care and treatment as part of
by the patient was needed.                         the pre-operative checklist. An audit to
    1. 10 of 35 (29%) Consents for                 monitor compliance (concurrent with the
        Anesthesia and Sedation were not           H&P audit) will begin February 1, 2009
        completed in entirety and/or correctly.    and results posted in the units.
    2. Three of 35 (9%) records did not
        contain a consent for care and
        treatment.

The goal of the informed consent process is to
establish a mutual understanding between the
patient and the physician or other licensed
independent practitioner who provides the
care, treatment, and services about the care,
treatment, and services that the patient
receives. This process allows each patient to

                                                                                 B-39
                                                         Parkland Health & Hospital System
                                                               Internal Audit Services
                                                         Audit Follow-Up Summary Report
                                                           Fiscal 3rd & 4th Quarters 2010
                                                    All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                       Responsible Management                  Target     Complete   Observation Title & Auditor Comments
                Report Date                            Original Management Response                Date        Date      and/or Follow Up Mgmt Responses


fully participate in decisions about his or her
care, treatment, and services.

2008-021 ASC                                        Brad Simmons                                 Status In              Lending/Leasing Forms
1/14/2009                                                                                        Progress               4. Lending/Leasing Equipment/Supplies

OR charge nurses complete the                       Effective January 19, 2009 all               1/19/2009              All equipment/supplies leaving the
Lending/Leasing equipment/supplies form to          lending/leasing of equipment and              6/7/2010              Operating Suite for destination other than
ensure equipment/supplies that are borrowed         medical supplies will be coordinated                                Biomed should be recorded on the
by other hospitals are documented and               through the charge nurse of the day.                                Loaned/Borrowed Form and placed in the
tracked appropriately. The information              The ADON will monitor the return of all                             log book. IAS randomly selected 10 items
collected on this form gives the OR the ability     equipment on a weekly basis. The                                    from the log book that were most recently
to assign accountability for losses, damages,       ADON has scheduled a meeting with his                               loaned out in September 2010. IAS noted
restitution and corrective measures. If the item    counterparts from other organizations to                            the following:
was not returned/replaced within 14 days the        review our current practice of medical                              A. Three of 10 (30%) forms were not
borrowing party should be billed at cost plus       supplies. This review will be modified to                           completed with all the required criteria.
5%. IAS reviewed 40 Lending/Leasing forms           reflect best practice and the policy and                            B. The Business/Technical Manager
in the binder stored in the OR main office. The     procedure will updated to reflect any                               located 10 of 10 (100%) yellow copies.
following was noted.                                changes. Audits will be conducted
     1. 40 of 40 (100%) forms were not              monthly for compliance and reported at
          completed in entirety and/or correctly.   the unit level. Education of this addition
          Several forms lacked the borrower's       to the charge nurse role has been
          anticipated date of return, requesting    completed.
          persons name, borrower's signature
          and/or date, received by parties
          name, date received back, and the
          model/serial number.
     2. In 32 of 40 (80%) forms IAS was
          unable to determine if the
          supplies/equipment were replaced or
          returned within 14 days because the
          employee who accepted the items did
          not document the date they were
          received back. Without the date of
          return IAS was unable to determine if
          the borrower should have been billed.
     3. The Business Support Manager was
          unable to locate 19 of 40 (48%) yellow


                                                                                   B-40
                                                     Parkland Health & Hospital System
                                                           Internal Audit Services
                                                     Audit Follow-Up Summary Report
                                                       Fiscal 3rd & 4th Quarters 2010
                                                All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                    Responsible Management                  Target     Complete    Observation Title & Auditor Comments
               Report Date                         Original Management Response                Date        Date       and/or Follow Up Mgmt Responses


      copies of the Lending/Borrowing
      forms that should be filed according to
      the departmental procedure.
   4. According to the Director of
      Perioperative Services the OR does
      not charge when hospitals do not
      return borrowed supplies that are on
      national back order.


2008-021 ASC                                    Brad Simmons                                 1/26/2009   5/6/2010    a. Operating Room Procedures
1/14/2009                                                                                                            5. Policies and Procedures

2008-021 ASC                                    Brad Simmons                                  Status                 b. Clinic Appointment Scheduling
1/14/2009                                                                                     Open                   7. Scheduling Process

The Clinic Schedulers are not entering the      All OR Pre-op work up appointments           7/30/2009               IAS is currently reviewing data. Testing will
service and requested surgery date in the       are consistent with the ASC process.                                 be completed first quarter of Fiscal Year
appointment notes for the Pre-op                With the help of the IT department we                                2011.
Appointments. In addition, they are not         were able to map all work up
scheduling both an appointment with the         appointments to include financial
Financial Counselors for the Pre-op             counseling and the clinical work up. This
Appointment. As a result, the Surgical          was implemented prior to December
Procedure Coordinator does not have enough      2008.
information to open a Surgical Case for Pre-    Preliminary meetings have been
op documentation in OpTime and is spending      conducted with Surgical Clinic
excess time researching to obtain the needed    Management to review current surgical
information.                                    scheduling as well as Pre-op
                                                appointment scheduling processes in an
                                                effort to identify opportunities for
                                                improvement. Work flows, policies and
                                                procedures will be revised to reflect best
                                                practices.

2008-021 ASC                                    Brad Simmons                                 7/30/2009   6/30/2010   a. Roles and Responsibilities
1/14/2009                                                                                                            7. Scheduling Process

2009-004 Pharmacy Administration                Brad Simmons                                 Status In               b. Missing Medication Order


                                                                               B-41
                                                          Parkland Health & Hospital System
                                                                Internal Audit Services
                                                          Audit Follow-Up Summary Report
                                                            Fiscal 3rd & 4th Quarters 2010
                                                     All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                        Responsible Management                Target     Complete   Observation Title & Auditor Comments
                Report Date                             Original Management Response              Date        Date      and/or Follow Up Mgmt Responses


6/13/2007                                                                                       Progress               4. Incomplete Chart Documentation

For 1 of 30 patients tested (3%), a PM&R             The staff will be reeducated and a         6/12/2007              As of 7/26/10, IAS identified one of ten
clinic provider’s progress notes did not specify     follow-up audit will be conducted every                           (10%) PM&R Clinic patients with
the drug strength for a triamcinolone injection.     90 days for one year.                                             Arthrocentesis Injections who had
There was no medication order in the chart.                                                                            incomplete chart documentation.
Triamcinlone is available in two strengths (40
milligram and 50 milligram). The patient was
charged for the 40 milligram injection
($75.12).

2009-006 Equipment Rental                            Brad Simmons                               5/1/2010    8/5/2010   a. Equipment Tracking
9/22/2009                                                                                                              1. Equipment Tracking and Invoice
                                                                                                                       Reconciliation

2009-006 Equipment Rental                            Brad Simmons                               12/1/2009   6/2/2010   b. Equipment and Other Rentals
9/22/2009                                                                                                              1. Equipment Tracking and Invoice
                                                                                                                       Reconciliation

2008-021 ASC                                         Brad Simmons - Jack Kowitt                 Status In              a. Log Verification
1/14/2009                                                                                       Progress               10. OpTime Data Integrity

While OpTime has hard stop requirements              The Epic logging function design           1/14/2009              As of 9/30/2010, IAS is reviewing log data
built in for the "most important" elements;          reflects the needs of the OR department                           for Operational Improvement.
these stops will only prevent the user from          for processing logs when available
verifying their portion of the log (pre-op, intra-   information is incomplete or when it may
op, or post-op), they do not prevent the log         be incomplete. Any other design posed
from posting. Therefore, logs can be posted          to possibility of interference with OR
with incomplete data.                                processes. Correct use of the verify
                                                     function will be reinforced through OR
                                                     Management and their policies.

2010-002 Radiology Administration                    Robin Stults                                Status                c. Diagnosis
5/25/2010                                                                                        Open                  2. Coding Compliance

Five of the 22 (23%) procedures reviewed             HIM follows the "official coding and       7/1/2010               Documentation was provided by HIM on
have diagnosis code reporting errors. Of those       reporting" guidelines as published by                             6/30/10 indicating coder education had
5 with errors (note that a claim for one             the American Hospital Association                                 been provided in June, 2010. This training
radiology procedure may have multiple                (AHA) Coding Clinic for ICD-9-CM. All                             covered the guidelines for outpatient

                                                                                   B-42
                                                        Parkland Health & Hospital System
                                                              Internal Audit Services
                                                        Audit Follow-Up Summary Report
                                                          Fiscal 3rd & 4th Quarters 2010
                                                   All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                      Responsible Management                    Target     Complete    Observation Title & Auditor Comments
                Report Date                           Original Management Response                  Date        Date       and/or Follow Up Mgmt Responses


diagnosis reporting errors):                       coding staff are instructed to assign                                  services coding and reporting as well as
    1. 3 diagnosis codes are missing,              codes based on provider documentation                                  PHHS HIM-specific coding and abstracting
        resulting in a lack of medical necessity   in the medical record. If the provider has                             guidelines.
        justification for the procedures           appropriately documented the reason
        performed; and                             for the services/procedures, medical                                   IAS will test a sample of 10 records for
    2. 3 diagnosis codes are incorrectly           necessity should be met. Medical                                       diagnosis accuracy at the time testing is
        reported, one of these resulting in a      necessity should not be the principle                                  performed for charge capture accuracy in
        lack of medical necessity justification    reason for selecting a diagnosis code as                               early November.
        for the procedures performed.              it can be considered maximizing.
                                                   Reconciling the proper assignment of
Although the errors noted are not all              diagnosis codes to multiple contact
government payor accounts, diagnosis codes         service numbers(CSN) is very
are assigned according to chart                    challenging to navigate and requires
documentation for all payors.                      close attention to details. HIM will
                                                   provide coder education regarding the
                                                   proper assignment of codes based on
                                                   the documentation in the medical record
                                                   and the importance of associating the
                                                   proper codes to the correct CSN.

2009-004 Pharmacy Administration                   Paula Turicchi                                12/12/2007   7/13/2010
6/13/2007                                                                                                                 3. Medication Overcharges

2009-009 Family Planning                           Paula Turicchi                                10/31/2007   7/1/2010
7/28/2009                                                                                                                 4. Prompt Service

2009-009 Family Planning                           Paula Turicchi                                Status In
7/28/2009                                                                                        Progress                 5. Charge Capture

All patient charges and visits should be           Clinic staff will be instructed to verify     10/18/2007               As of 10/13/10, testwork is in progress.
reconciled at the end of each clinic day to        charge entry at the end of the clinic.        12/31/2009
ensure that all appropriate technical and          This topic will be included in the staff
professional charges have been entered. Six        training scheduled for October 18, 2007.
of 30 (20%) encounter forms contained errors       Sliding fee scales and other information
that were not corrected at the end of the clinic   is routed to the PFS supervisors by the
day. IAS documented the following:                 program administrator on a regular
     1. On 1 of 6 (17%) accounts the               basis. PFS supervisors will post the
         discharge clerk incorrectly entered the   latest files to a shared drive; information


                                                                                   B-43
                                                         Parkland Health & Hospital System
                                                               Internal Audit Services
                                                         Audit Follow-Up Summary Report
                                                           Fiscal 3rd & 4th Quarters 2010
                                                    All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                       Responsible Management                    Target     Complete   Observation Title & Auditor Comments
                Report Date                            Original Management Response                  Date        Date      and/or Follow Up Mgmt Responses


       professional charge.                         will be added as it becomes available.
    2. Five of 6 (83%) errors were PFS
       employee errors. On 3 accounts
       patients qualified to pay co-pay.
       However, the co-pay calculation was
       not completed by several different
       financial counselors. One account
       was registered incorrectly. On one
       account the total charges under Co-
       Pay Calculation was incorrectly
       calculated.


2009-013 Grant Management                           Paula Turicchi                                  Status
3/23/2010                                                                                           Open                  1. Underexpended Grant Funds

For 8 of 30 grants tested (27%), departments        Funding for the outreach project was not       8/31/2010              The Fiscal Year 2010 grant year ended on
utilized less than 90% of available funding.        utilized in the first year due to multiple                            8/31/10. Once the final Financial Status
Factors contributing to the underutilization        negotiations and changes with the                                     Report is submitted, IAS will determine
included delayed receipt of invoices, hiring        Texas Department of State Health                                      how much of the grant funding was spent
delays, restrictions imposed by the grantor,        Services and Regional Office of                                       during Fiscal Year 2010.
and overestimation of expenses. In addition,        Population Affairs. The State was not
IAS noted that for 86% (26 of 30) of the grant      clear on the goals, objectives, and
applications, departments did not seek              outcomes desired for the grant at the
assistance from Grants Management to                beginning of the grant year. Multiple
develop the budget.                                 meetings and phone conferences were
The following details the underutilization of the   held with Parkland staff to determine the
eight grants identified:                            aim of the program and acceptable
      1. Program: AETC - Ryan White F               operational uses for the funding. As a
                                                    result, the State awarded the grant and
        Amount Awarded: $1,553,167                  executed the contract about 5 months
        Expenditures Reported to Grantor:           into the grant year, leaving little time for
        $1,242,211Funding Utilized: 80%             needs assessment, contract negotiation
        Explanation: Waiting for two                with subcontractors, hiring outreach
        subcontractors to submit final invoices     personnel, etc. Program goals,
        since June 2009                             objectives, and metrics are in place.
                                                    Funds will be spent as expenses are
                                                    incurred. Difficulty in hiring an outreach


                                                                                    B-44
                                                     Parkland Health & Hospital System
                                                           Internal Audit Services
                                                     Audit Follow-Up Summary Report
                                                       Fiscal 3rd & 4th Quarters 2010
                                                All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                    Responsible Management                Target   Complete   Observation Title & Auditor Comments
               Report Date                         Original Management Response              Date      Date      and/or Follow Up Mgmt Responses


   2. Program: Nurse Family Partnership         nurse practitioner for the grant may lead
                                                to under-expended funding again this
       Amount Awarded: $806,284                 year. However, far more of the grant
Expenditures Reported to Grantor:               funding will be spent during FY 2010.
$410,145Funding Utilized: 51%
Explanation: Hiring delays
   1. Program: Project Support - Frew Pedi
       Integrated MH

       Amount Awarded:
       $484,650Expenditures Reported to
       Grantor: $144,578
       Funding Utilized: 30%Explanation:
       Hiring delays, staff vacancies, and
       insufficient documentation to bill for
       pediatrician-therapist consultations

   2. Program: Family Planning Outreach -
      Title X - Hard to Reach Populations -
      African Americans

          Amount Awarded: $450,000
Expenditures Reported to Grantor: $57,093
Funding Utilized: 13%Explanation: Shortened
grant year, hiring delays, project scope
change, and changes to the state's contract
notification process
     1. Program: MRSA Colonization &
          Control in the Cook County Jail

       Amount Awarded: $282,762
       Expenditures Reported to Grantor:
       $218,949Funding Utilized: 77%
       Explanation: Delayed project start

   2. Program: Ryan White Part D - Youth



                                                                              B-45
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management             Target     Complete    Observation Title & Auditor Comments
               Report Date                           Original Management Response           Date        Date       and/or Follow Up Mgmt Responses


        Angle

       Amount Awarded: $132,253
Expenditures Reported to Grantor:
$100,693Funding Utilized: 76%
Explanation: Project scope change
   1. Program: HOMES CHS-Federally
       Qualified Health Center

        Amount Awarded:
        $89,845Expenditures Reported to
        Grantor: $74,016
        Funding Utilized: 82%Explanation:
        Overestimated medical equipment
        expense

    2. Program: Reducing HAI

        Amount Awarded: $47,455
Expenditures Reported to Grantor: $19,692
Funding Utilized: 41%Explanation: Delayed
operating decisions by grantor


2009-013 Grant Management                         Paula Turicchi                          9/10/2010   9/30/2010   b. 100% Grant Funded
3/23/2010                                                                                                         3. Board Reporting

2010-004 Post Partum                              Paula Turicchi                           Status                 a. Charge Capture
8/24/2010                                                                                  Open                   1. Supply Charge Capture

Post Partum patient care staff are responsible    Post Partum staff will be trained       8/15/2010               IAS will test once training is completed and
for tracking supplies used in each patient's      regarding the accuracy of dates on                              allow time for transactions to be processed
care by putting an inventory sticker and a date   charge sheets.                                                  after training.
of service on each patient's daily charge
sheets. Material Services then picks up the
charge sheets from the units and ensures that
all charges are entered accurately into Epic.
Approximately $42,000 in supply charges are

                                                                               B-46
                                                      Parkland Health & Hospital System
                                                            Internal Audit Services
                                                      Audit Follow-Up Summary Report
                                                        Fiscal 3rd & 4th Quarters 2010
                                                 All Audits with Completed Dates > 3/31/2010

       Audit No./Name & Observation                    Responsible Management                 Target     Complete   Observation Title & Auditor Comments
                Report Date                         Original Management Response               Date        Date      and/or Follow Up Mgmt Responses


entered for Post Partum monthly.
IAS randomly selected and tested 30 Post
Partum patients and reviewed their supply
charges for accuracy and identified the
following:
     1. 4 of 30 (13%) charges could not be
         reconciled because charge sheets
         could not be located by Material
         Services.
     2. For 25 of the remaining 26 (96%)
         charge sheets, the service date did
         not match the date in EPIC.
     3. 1 of 26 (3%) charge sheets entered in
         EPIC were allocated to the incorrect
         cost center.
     4. 1 of 26 (3%) charge sheets do not
         match charges in EPIC.
     5. 1 of 26 (3%) charge sheets was not
        entered into EPIC.
     6. 1 of 26 (3%) charge sheets did not
        have a service date completed by the
        Post Partum patient care staff.




2010-004 Post Partum                             Paula Turicchi                               Status
8/24/2010                                                                                     Open                  2. Pharmacy Charge Capture

IAS compared 30 Post Partum patients for         Nursing staff will be retrained regarding   8/15/2010              IAS will test once training is completed and
EPIC charges billed to the medications           Pyxis procedures.                                                  allow time for transactions to be processed
administered to the patient. IAS also verified                                                                      after training.
that the dose administered was documented
and that it was administered according to the
instructions.
Eight of 30 (26%) patient’s Medical
Administration Records (MAR) do not


                                                                                B-47
                                                       Parkland Health & Hospital System
                                                             Internal Audit Services
                                                       Audit Follow-Up Summary Report
                                                         Fiscal 3rd & 4th Quarters 2010
                                                  All Audits with Completed Dates > 3/31/2010

      Audit No./Name & Observation                      Responsible Management             Target   Complete   Observation Title & Auditor Comments
               Report Date                           Original Management Response           Date      Date      and/or Follow Up Mgmt Responses


reconcile to the charges in Epic. The following
is a breakdown of the drug administrations:
1. 8 instances where a patient was charged
     for medications not administered. Most
     commonly due to medications not being
     returned to pharmacy.
2. 5 instances where a medication was
     administered to the patient, but no
     charges exist. Most commonly due to
     nurses taking medications out of Pyxis
     when retrieving medications for other
     patients.
Post Partum stated that some of the
discrepancies may be due to the nurses not
being able to return the medications for
infection control reasons. However,
procedures are in place for how nursing
should document waste due to exposure to
infectious patients.
Pharmacy conducts weekly monitoring
reconciling 10 medicines charged in each unit;
however, the review is not designed to identify
the exceptions noted in this review.




                                                                              B-48
Internal Audit Services
Annual Report
Fiscal Year 2010


During Fiscal Year 2010, Internal Audit Services (IAS) presented a number of reports and issues
to Parkland Management (Management) and the Dallas Country Hospital District Board of
Managers (Board). Projects were the result of our annual audit plan approved by the Board in
September 2009 and other projects performed at the request of Management and/or the Board.

This document summarizes the internal audit activity for the fiscal year.

Compliance Reviews

IAS performs compliance reviews to determine whether processes and controls are in compliance
with regulations and processes are functioning as intended; some examples of standards used
for testing include Centers for Medicare & Medicaid Services Conditions of Participation, Joint
Commission, and federal/state laws. The following reviews were completed during the year.

Durable Medical Equipment

This review was presented in Executive Session.

Outpatient Procedure Area Coding

This review was presented in Executive Session.

Projects in Draft
Evaluation & Management Review
Self-Administered Drugs Review

Information Technology Audits

IAS provides Parkland with a variety of information technology services including audits of
general system controls, application controls, data integrity, physical security, information
security, and internal data support. IAS also serves as consultants on various systems
implementation projects. Criteria used in evaluating information technology applications,
procedures, and implementations is derived from COBIT (Control Objectives for Information and
Related Technology) and Industry Best Practices. The following integrated audits were
completed during the year.

ANSOS – Automated Nurse Staffing Office System

This area received a moderate risk rating because the ANSOS staff scheduling system is working
as intended; however, functionality and user satisfaction can be improved by implementing the
PeopleSoft to ANSOS interface and researching ANSOS’s Assignment and Workload Manager
(AWM) module acuity tool. Hospital nurse staffing is a matter of high concern because of the
effects it can have on patient safety and quality of care. Nursing staff scheduling is the problem
of determining a work schedule for nursing staff that is both reasonable and efficient.

Cerner Pathnet

This review received a moderate risk rating because charge transactions were posted in EPIC
where the order was canceled in Cerner PathNet, Cerner Active Recovery (AR) system has not
been fully tested as planned, and multiple provider records are in the PathNet application with
duplicate provider identification numbers. Additionally, manual operations are in practice to
extract data from CACTUS and transform data to the PathNet system. The Cerner PathNet
laboratory information system is of high importance to Parkland because it provides clinicians


                                                C-1
with technology automating the operational and managerial sides of the Pathology Department.
The Cerner PathNet system provides useful and timely information for monitoring the
Organization’s Quality goal of Operational Excellence to meet Lab Turnaround Time.

Projects in Draft
E-Signatures

Operational/Financial Audits

IAS performs operational and financial audits to evaluate whether hospital departmental controls
are effective and efficient, as well as to evaluate for sufficient controls over financial transactions.
Unlike external financial audits, internal financial audits do not express professional opinions on
presentation of financial statements. Committee of Sponsoring Organizations (COSO), a
common definition of internal controls, standards, and criteria to assess controls, as well as
industry best practice criterion are used in evaluating operational effectiveness and efficiency.

Travel

This area received a moderate risk rating for performance because there are documented
controls in place for how travel should be managed; however, controls could be improved by
implementing a strong quality assurance review prior to payment, as well as updating procedures
to address additional recurring situations. This area received a medium rating for importance due
to the financial impact and the potential negative public perception that could result from travel
abuse or fraud.

COPC – Garland and Vickery

Since the areas of noncompliance identified during this review do not impose a direct patient care
risk, the area received a moderate risk rating. However, the errors affect efficiency and
effectiveness of operations within the COPC's. This area received a moderate importance rating
because of its operational complexity, patient care impact, financial statement impact, and recent
changes/turnover.

Grant Accounting

This audit received a moderate risk rating because of failure to identify all grant-related expenses,
which could impact Parkland's ability to meet its financial goals. This audit received a high
importance rating because Parkland's 2009-2010 grant awards total $22.8 million.

Post Partum

This audit received a moderate risk rating due to lack of proper training and incorrect posting of
charges. In addition, the reconciliation of medications administered versus charges hinders
Parkland's ability to meets its strategic goals of stewardship: value driven business processes for
cost effective care and delivery. This area received a moderate rating for importance due to the
patient volume and financial impact. Parkland's strategic goals are to provide services that are
comparable and competitive with other leading private sector health systems.

Engineering Services

A moderate risk was assigned because the areas of noncompliance include hospital policy,
departmental procedures and potentially increase Parkland's liability. Additionally, inadequate
controls in the department hinder Parkland's ability to meet strategic goals for quality, service,
high performance, and stewardship. Engineering is of high importance due to the volume and the
impact the services have on the daily operation of Parkland's facility. Engineering's
responsibilities contribute to Parkland's strategic goal to produce leading patient outcomes,
advancing patient safety and care effectiveness.



                                                  C-2
Projects in Draft
Procurement

Integrated Audits

Integrated audits are designed to take a more comprehensive view of an area and combine the
operational/financial audit process with either or both the compliance or information technology
audit techniques.

Respiratory Care/Clinivision

A high risk was assigned because inadequate controls have the potential for financial risk and
reduced efficiency. A high risk was assigned due to protocol concerns, charging issues, and non-
compliance with HIPAA.

Radiology

This review was presented in Executive Session.

Special Projects

Special projects represent activities performed at the request of the Board or Audit Management.
During Fiscal Year 2010, IAS also classified routine annual audits into this project type. All
special projects are noted below.

    •   Physical Inventory
    •   Cash Management
    •   External Audit Assistance – IAS provided 621 hours to Deloitte for completion of the
        annual external audit.
    •   HIPAA Monitoring (Privacy & Security)
    •   List of Excluded Individuals
    •   Continuous Monitoring
             o Multiple MRI’s within one week
             o Documentation of Pain Scores
             o Multiple Orders by Physicians
    •   Public Information Act Requests
    •   Internal Audit Services Data Plan
    •   Fraud Awareness – IAS worked with individuals from the Police Department, Patient
        Financial Service, Information Security, and Corporate Compliance to document a fraud
        risk assessment, as well as an Awareness Program.
    •   Fiscal Year 2011 Audit Planning – IAS implemented a new audit planning process,
        which is control based. The new projects will evaluate the design and effectiveness of
        controls that are in place to mitigate organizational risks. Fiscal Year 2011 will be a
        transitional year, so the plan will consist of control, entity, and periodic reviews.
    •   Management Request
             o Attending Physician
             o Stemmons/Chase Build-out
             o Payroll Analysis
             o Time Edits
             o First Year Turnover Validation
             o Oracle License Review
    •   Board Request
             o Attending Physician
             o Legal Fees
             o Payments > $50K




                                               C-3
Consults

In accordance with IIA standards, IAS performs consultation services at the request of Parkland
Management. This value-added service is advisory in nature and is an independent review
focusing on areas of Management concern.

    •   New Parkland Hospital
    •   Lawson Strategic Sourcing
    •   Joint Commission Patient Rights & Responsibility Work Team
    •   Remediation Activities
    •   CORE Cash Register System
    •   Fixed Assett Monitoring
    •   Patient Valuables and Patient Deposits
    •   PeopleSoft Upgrade

Follow-up Projects

Internal Audit has provided quarterly reports on previously reported audit recommendations and
management responses. During Fiscal Year 2010, IAS tracked 229 recommendations and action
plans. Of the 229, 152 of the items had been addressed, 73 remain open, and 4 with
management acceptance of risk.

Time Summary

The following summary reflects the Fiscal Year 2010 Audit Plan budget to the actual time
dedicated for indirect and direct audit hours. The variances in total budgeted time to actual time
expended is largely in part to training and orientating new employees to the audit process, as well
as a resource on family medical leave of absence. IAS had FTE vacancies of 2.79% during the
year.

                                             Budget            Actual         Variance
 Indirect Hours                              10,706            11,715           1,009
 Direct Hours                                22,227            18,103          (4,124)
 Totals                                      32,933            29,818           3,115


FY 2010 Financial Performance

                                            Budget             Actual        Variance      Percent
 Salaries                                 $1,392,987         $1,200,942      $192,044      13.8%
 Supplies                                    $52,051           $47,048         $5,003       9.6%
 Total                                    $1,445,038         $1,247,972      $197,047      13.6%




                                               C-4
DALLAS COUNTY HOSPITAL DISTRICT
PARKLAND HEALTH & HOSPITAL SYSTEM


PHARMACY SERVICES




DATE:    October 13, 2010


TO:      Audit & Compliance Committee
         PHHS Board of Managers


FROM:    Vicki Crane, Senior Vice President
         Clinical Support


RE:      Post Partum Audit, Report No. 2010-004


         Attached please find an update for the Pharmacy Charge Capture recommendation in the
         Post Partum Audit report. The original report was presented at the August 2010 Board of
         Managers meeting.


         Regards.




         Attachments

CC:      Ron J. Anderson, M.D., President & Chief Executive Officer
         John Dragovits, Executive Vice President & Chief Financial Officer
         John Haupert, Executive Vice President & Chief Operating Officer
         Vic Summers, Senior Vice President, Internal Audit Services
         Amy LaBarge, Director, Internal Audit Services
DALLAS COUNTY HOSPITAL DISTRICT
PARKLAND HEALTH & HOSPITAL SYSTEM


PHARMACY SERVICES




Interim Action Plan for Post Partum Pharmacy Charge Capture


The recommendation from the original Post Partum Audit report No. 2010-004 regarding pharmacy
charge capture was twofold:

    •   post partum must account for and document all medications administered, return, discontinued
        and/or waste
    •   pharmacy should implement an automated reconciliation between the MAR and the patient
        charges with Epic and identify instances where unadministered medicines were not returned

Post partum is implementing a revised medication system to dispense unit of use medications (rather
than bulk) to inpatients. This more robustly supports a one to one match between medications
ordered/dispensed and medications used, wasted or returned. This strategy contains three components:
the unit of use drugs being added to Pyxis, an order set change, and inservicing of nurses. Post partum’s
target is to implement this new system on November 1. Follow-up audits will be performed in December.

Pharmacy has already enhanced the pharmacy audit tool to allow for enhanced chart reconciliation
between the electronic medication administration record (MAR) versus Pharmacy order entries,
dispensations. Ongoing reconciliations are currently being performed to catch and correct any variances.

This potential problem could be more widespread then post partum so a broader assessment is being
included in the current Deloitte revenue cycle consultation. Deloitte will also assess the longer term plan
of moving to charge on administration for inpatient medications. The goal would be to target moving to
charge on administration when bedside bar code administration of medications is implemented in March
31, 2013.




                                                    D-2
                                  Dallas County Hospital District
                                Parkland Health & Hospital System
                              Audit & Compliance Committee Meeting
                                         October 26, 2010

                                        Internal Audit Services
                                        Monthly Status Report


Audit Committee Reports
                                           rd    th
A. HIPAA Monitoring, Fiscal Year 2010 – 3 & 4 Quarters, Report No. 2010-501
                                                                  rd   th
B. Audit Management Response Follow-up Audit, Fiscal Year 2010 – 3 & 4 Quarters
C. Internal Audit Services Annual Report, Fiscal Year 2010

Executive Session
A. Outpatient Procedure Area Coding Review, Report No. 2009-307


Audits in Progress                                                         Status
•  Procurement Review                                                      Draft       DEC
•  ACS SLA & Invoice Review                                                Fieldwork
•  Compensation                                                            Planning
•  Stimulus Funds                                                          Planning

Audit Follow-up Summary Report                                             Status

•   Audit Management Response Follow-up Audit,                             Quarterly
    Fiscal Year 2011

Compliance Reviews In Progress                                             Status
•  Evaluation & Management                                                 Draft
•  Self Administered Drugs                                                 Draft
•  Inpatient/Outpatient Services in Appropriate Setting                    Fieldwork
•  Observation Services                                                    Fieldwork
•   Review of Federal and State Government Excluded Individuals/Entities   Quarterly
•   Regulatory Response Process                                            Planning

Consults and Other                                                         Status
•  Attending Physician Documentation                                       Draft
•  Physical Inventory, Fiscal Year 2010                                    Draft       DEC
•  CORE Cash Register System                                               Fieldwork
•  Deloitte External Audit Assistance                                      Fieldwork
•  Executive Incentive Plan                                                Fieldwork
•  Fixed Asset Monitoring                                                  Fieldwork
•  Independent Contractor                                                  Fieldwork
•  Payroll Analysis                                                        Fieldwork
•  Time Edits                                                              Fieldwork
•  Fraud Awareness                                                         Ongoing
•  Joint Commission Patient Rights & Responsibility Work Team              Ongoing
•  New Parkland – Outsource Contract                                       Ongoing
•  Remediation Activities                                                  Ongoing
•  Attending Physician Documentation                                       Planning
•  Cash Collections Threshold Monitoring                                   Planning
•  Documentation of Pain Scores                                            Planning
•  Medicare Secondary Payor Questionnaire - Monitoring                     Planning
•  Orders by Multiple Providers - Monitoring                               Planning
•  PeopleSoft Upgrade                                                      Planning
•  Patient Valuables and Patient Deposits                                  Delayed

				
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