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HomeMy WebLinkAbout2021-3 2020 Global Follow-up report (Final 11-30-20)2020 Global Follow-up Report #20/21-3 November 2020 2020 Global Follow-up Report Outstanding recommendations – 911 CSD Cash Handling, Health Benefits Trust, Health Services, Human Resources, Sheriff’s Office, Light fleet, Property & Facilities, Solid Waste To request this information in an alternate format, please call (541) 330-4674 or send email to David.Givans@Deschutes.org Deschutes County, Oregon David Givans, CPA, CIA County Internal Auditor 1300 NW Wall St Bend, OR 97703 Audit committee: Daryl Parrish, Chair - Public member Jodi Burch - Public member Tom Linhares - Public member Scott Reich - Public member Summer Sears - Public member Stan Turel - Public member Patti Adair, County Commissioner Nancy Blankenship, County Clerk Nick Lelack, Community Development Director 2020 Global Follow-up Report #20/21-3 November 2020 TABLE OF CONTENTS: HIGHLIGHTS 1. INTRODUCTION 1.1. Background on Audit …………………..………………………………..………………….. 1 1.2. Objectives and Scope ……………….…………………..…………………..……………… 1 1.3. Methodology …………………………………….………………………………………...… 1-2 2. FOLLOW-UP RESULTS …………………….………………..………………………………… 3-8 APPENDIX I – Updated workplan for identified outstanding recommendations (Status as of November 2020) .……................................ 9-21 2020 Global Follow-up Report #20/21-3 November 2020 Page 1 1. Introduction 1.1 BACKGROUND ON AUDIT Audit Authority: The Deschutes County Audit Committee has suggested that follow-ups occur within nine months of the reports. The Audit Committee would like to make sure departments satisfactorily address prior recommendations that have not been completed at the time of the initial or subsequent follow-ups. This is the tenth annual global follow-up looking back to unresolved recommendations in prior follow-ups. 1.2 OBJECTIVES and SCOPE “Audit objectives” define the goals of the audit. Objectives: The objective was to follow-up on previously incomplete recommendations. Scope: This 2020 Global follow-up included reports with incomplete recommendations that did not have a follow- up report completed in approximately a year. The audit reports in TABLE I are covered in this report. There are thirty-three recommendations included in this follow-up (as compared to twenty-two in the prior year, up 50%). Status was determined through information provided by departments in November 2020. The original internal reports should be referenced for the full text of recommendations and associated discussion. All internal audit performance reports are published on the County website at https://www.deschutes.org/administration/page/internal-audit-reports 1.3 METHODOLOGY The follow-up report was developed from information provided by appropriate staff in the associated departments. In cases where recommendations have not been implemented, comments were sought for the reasons why and the timing for addressing these. The follow-ups are, by nature, subjective. In determining the status of recommendations that were followed up, we relied on assertions provided by those involved and did not attempt to independently verify those assertions. 2020 Global Follow-up Report #20/21-3 November 2020 Page 2 Table I Reports and number of recommendations included in follow- up {Original reports hyperlinked} It is understandable that some of these recommendations will take more than one year to be completed. Departments should be acknowledged for the work and commitment to address the recommendations. Since no substantive audit work was performed, Government Auditing Standards issued by the Comptroller General of the United States were not followed. Department/ Area Original Report # Date Report Issued Last Follow-up Report Last Follow-up Date # of Original Recommendations # Recommendations in this follow-up % of Original 911 CSD Cash Handling (NEW) 18/19-4 Mar-19 19/20-8 Dec-19 6 1 17% Health Benefits Trust 12/13-11 Oct-13 19/20-3 Nov-19 7 3 43% Health Services - Fiscal Revenue Controls (NEW) 17/18-8 Oct-18 19/20-2 Aug-19 23 10 43% Human Resources – New Hires 08/09-16 Jan-10 19/20-3 Nov-19 26 3 12% Human Resources - Span of Control (NEW) 18/19-2 Feb-19 19/20-6 Nov 19 2 2 100% Sheriff’s Office - Inmate Health Services (NEW) 17/18-3 Jun-18 18/19-7 Mar-19 6 2 33% Sheriff’s Office - Inmate Health Standards (NEW) 17/18-7 Jul-18 18/19-7 Mar-19 1 1 100% Light Fleet 14/15-10 Jun-15 19/20-3 Nov-19 14 5 36% Property & Facilities 11/12-12 Sep-12 19/20-3 Nov-19 5 1 20% Solid Waste 16/17-6 Jan-18 19/20-3 Nov-19 18 5 28% Totals 108 33 31% 2020 Global Follow-up Report #20/21-3 November 2020 Page 3 2. Follow-up Results Figure I - How were recommendations implemented? The follow-up includes thirty-three (33) recommendations made over ten internal audit reports. The number of recommendations followed up on was up from twenty-two (22) in 2019. The number of outstanding recommendations represented thirty-one percent (31%) of the original recommendations (also, coincidently, 31% in 2019). For some of the reports, more than one follow-up has occurred. There are five new follow-up audits included in this Global follow-up with seventeen outstanding recommendations. A few completed reports had follow-ups that completed all recommendations in the first follow-up, so no additional follow-ups are required. The follow-up indicates twenty-seven (27) of these outstanding recommendations (or 82%) have been completed. Implementation is expected to take time for some recommendations, but the idea would be to have these incomplete recommendations resolved as soon as practicable. Figure I provides a summary of the change in status for these followed up recommendations. Eighteen percent (18%) of the reviewed recommendations are still underway for implementation. This compares with seventy-seven percent (77%) of the reviewed recommendations still underway for implementation in 2019. Complete 82% Underway 18% 2020 Global Follow-up Report #20/21-3 November 2020 Page 4 Figure II - How were recommendations implemented by department and report? A detailed listing of all the recommendations followed up on and their status is included at the end of the report in Appendix I. In interpreting the status, the County Internal Auditor may sometimes raise or lower the status provided by the department based on the communication(s) received from the department. Figure II provides a breakdown of the status of these recommendations by department and audit report. Generally, there is a natural progression seen as “planned” implementation moves into an “underway” status and then to “complete”. 2020 Global Follow-up Report #20/21-3 November 2020 Page 5 Figure III - How has the status changed for outstanding recommendations? Figure III indicates the beginning status of recommendations coming into this follow-up and whether they have moved from one category to another. Lack of movement does not necessarily mean that no work was performed, but that it has not moved from one category to another. Figure III was designed to identify movement in recommendations. Table II indicates for these reports 94% of the original recommendations accepted have been deemed completed. This does not include all the reports fully completed (over this period) and not part of the 2020 Global Follow-up Report #20/21-3 November 2020 Page 6 Table II Reports, number of recommendations included in follow- up and percentage still outstanding global follow-up. In 2019, the global follow-up completion rate was 76%. After this follow-up, six percent (6%) of the original recommendations for these reports are still outstanding. Department/ Area Original Report # # of Original Recommenda- tions # Recommenda- tions in this follow-up % of Original # of Recom- mendations still Outstanding % Outstanding 911 CSD Cash Handling (NEW) 18/19-4 6 1 17% 0 0% Health Benefits Trust 12/13-11 7 3 43% 0 0% Health Services - Fiscal Revenue Controls (NEW) 17/18-8 23 10 43% 4 17% Human Resources – New Hires 08/09-16 26 3 12% 0 0% Human Resources - Span of Control (NEW) 18/19-2 2 2 100% 1 50% Sheriff’s Office - Inmate Health Services (NEW) 17/18-3 6 2 33% 0 0% Sheriff’s Office - Inmate Health Standards (NEW) 17/18-7 1 1 100% 1 100% Light Fleet 14/15-10 14 5 36% 0 0% Property & Facilities 11/12-12 5 1 20% 0 0% Solid Waste 16/17-6 18 5 28% 0 0% TOTALS 108 33 31% 6 6% 2020 Three-Year Implementation Rate Implementation rates are similar to completion rates. However, from an organizational standpoint more than a year is generally accepted for implementing recommendations. The Government Accountability Office (GAO) in their FY 2020 Performance and Accountability report, use a four-year time period and had a 77% implementation rate. The calculations below for Deschutes County for 2020 use a three-year period and come up with a 90% implementation rate for the included audit reports. 2020 Global Follow-up Report #20/21-3 November 2020 Page 7 Figure IV Status of recommendations for reports that have come up for follow-up for the prior three years. Figure IV shows the implementation rate of accepted recommendations for the 11 reports issued in the last three years and that have come up for follow-up. The number of recommendations for this three- year period was 106, with 95 of those recommendations having been completed, and 11 recommendations still outstanding. 2020 Global Follow-up Report #20/21-3 November 2020 Page 8 Footnote on Figure IV While the same six audits with follow-up reports are listed in both Figure III and Figure IV, Figure III includes four reports not included in Figure IV, and Figure IV includes five reports not included in Figure III. Yet, both figures illustrate the same conclusion: The implementation rate for audit recommendations by Deschutes County departments is extremely high. 2020 Global Follow-up Report #20/21-3 November 2020 Page 9 APPENDIX Appendix I – Updated workplan for identifed outstanding recommendations. (status as of November 2020) Included as “Complete” were statuses indicating they were complete and had some form of ongoing work; and withdrawn due to the recommendation no longer being relevant in the current environment. Items that are not complete are grayed out. Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 1 911 CSD Cash Handling 18/19-4 6 It is recommended for County Finance to evaluate whether the District’s facts require any non-cash compensable items be included in wages. Underway Complete Based on an evaluation of this section of the IRC, the provision of County logoed clothing supplied not less than annually and for an amount of not more than $75 appears to meet the intent of the Code and qualify as a de minimis benefit. 2 Health Benefits Trust 12/13- 11 1 It is recommended for management of the Plan to develop and implement a consistent approach to assessing the performance of the DOC. Underway Complete A subcontractor of Medcor, myCatalyst, completed a Population Health Study and Onsite Clinic Analysis in August 2018. The analysis compared the cost of a DOC visit vs a clinic in the community. The analysis found a cost savings of $837,258. The analysis was reviewed by Davidson Benefits Consulting. The DOC RFP will include a requirement for responders to propose methods to assess performance at the DOC. 2020 Global Follow-up Report #20/21-3 November 2020 Page 10 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 3 Health Benefits Trust 12/13- 11 2 It is recommended for County management to develop an approach to handling Plan and DOC staffing and oversight. Underway Complete An Executive Committee has been formed and includes the HR Director, CFO, County Administrator, and Deputy County Administrator. The committee will meet as follows: Aug/Sept to review plan renewal, December for HBT budget, and Feb/March to review plan analytics. 4 Health Benefits Trust 12/13- 11 4 It is recommended, after adequate time sheet information has been collected, the County assess the cost to the County and departments for employee usage of the DOC on work time and whether they want to continue the practice at this level. Underway Complete HR established a payroll code for DOC visits. The use of this payroll code varies by department and whether an employee is exempt vs non-exempt. For example, Exempt employees do not need to account for short periods of leave. In FY 19-20, a total of 370.60 hours was coded as DOC leave; 91.5 hours attributed to Exempt employees and 279.1 hours attributed to Non- Exempt employees. At this point, it is not recommended to create a countywide policy requiring the use of the DOC leave code. 2020 Global Follow-up Report #20/21-3 November 2020 Page 11 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 5 Health Services - Fiscal Revenue Controls 17/18-8 1 It is recommended for the Department to actively utilize and share information with the Administrative Services Division, County Finance, and County Administration for all financial discussions involving the CCO on resource modeling, reconciliations, and accounting issues. Underway Complete During the 2020 negotiations, the Department's Behavioral Health and Administrative Services Division participated in CCO financial discussions collaboratively. It has become a regular practice in the Department to provide regular updates to County Administration and Legal apprised of the agreement's status, reconciliations, and any accounting issues. Legal will be kept in the loop as the contract negotiations continue. 6 Health Services - Fiscal Revenue Controls 17/18-8 4 It is recommended for the billing manager to develop written procedures for staff on billing and collections procedures including how to properly process and apply payments received. Underway Underway There are 15 processes and procedures drafted. Target date for completion is January 2021. Jan-21 7 Health Services - Fiscal Revenue Controls 17/18-8 9 It is recommended for the Department to consider centralizing the overall department collection supervision duties. Planned Complete The department evaluated restructuring to allow for all collection activities to fall under one supervisor, and it was determined not realistic given the various lines of business. 2020 Global Follow-up Report #20/21-3 November 2020 Page 12 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 8 Health Services - Fiscal Revenue Controls 17/18-8 10 It is recommended for the Department to put in place appropriate controls over adjustments to any collections. Planned Complete Billing/Fiscal supervisor now has access to a vast array of reports that help track adjustments and write-offs. Additionally, a more robust Daily Cash workbook provides a detailed breakdown on money received (collections) that will immediately trigger an error if money is voided for any reason. 9 Health Services - Fiscal Revenue Controls 17/18-8 13 It is recommended for the Department to develop written policies and procedures over the billing and collection oversight activities. Underway Underway This goal is being included with the activities in recommendation #4 Jan-21 10 Health Services - Fiscal Revenue Controls 17/18-8 14 It is recommended for the Administrative Services Division (or selected supervisors) periodically audit gift card accounting in a comprehensive way and periodically check custody logs for completeness and accuracy. Underway Underway Administrative Services conducts quarterly audits for at least one program currently. At end of fiscal year, an outstanding gift card log is submitted from all programs, which was first implemented in FY 2020. This will assist in auditing and tracking gift card usage moving forward. Jun-21 2020 Global Follow-up Report #20/21-3 November 2020 Page 13 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 11 Health Services - Fiscal Revenue Controls 17/18-8 19 It is recommended for the Environmental health program and Vital Records Program to consider how they might consolidate receipting. This might allow them to eliminate the duplicate receipting efforts through importing those transactions to Munis. Underway Complete Environmental Health continues to enter some receipts into Health Space, which we import into Munis, and some directly into Munis (Health Space does not accommodate all fees for which Health collects). Health is required by the state to use this state system, which is not fully compatible with Deschutes County's internal financial system. 12 Health Services - Fiscal Revenue Controls 17/18-8 21 It is recommended for the department to update their fiscal policies and procedures. Planned Underway Department underwent restructure of its chart of accounts. Furthermore, the Department hired an Accountant, who is reviewing procedures and updating/instituting processes where appropriate. Updating the fiscal policies and procedures following the process improvements expected to occur in 2021. Jun-21 13 Health Services - Fiscal Revenue Controls 17/18-8 22 It is recommended the department update their billing to follow the County fee schedule and/or develop and propose in the budget process a new fee schedule for these items. Underway Complete FY21 fees will be in line with ORS. 2020 Global Follow-up Report #20/21-3 November 2020 Page 14 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 14 Health Services - Fiscal Revenue Controls 17/18-8 23 It is recommended for the department to periodically review their billings for compliance to the County fee schedule. Underway Complete The Department met with all program managers for the FY21 fee process and reviewed County fee policies to ensure all fees are accurately captured. 15 Human Resources – New Hires 08/09- 16 3 It is recommended for County Legal Counsel to evaluate whether the authorization/disclosure forms currently being utilized comply with FCRA. Underway Complete Legal reviewed forms and confirm the County's compliance with FCRA. 16 Human Resources – New Hires 08/09- 16 3.1 It is recommended the County train and work with departments to establish meaningful procedures to comply with the FCRA. This might require some revision to the current background policy (HR-3) or personnel rules. Underway Complete The memo is completed and has been provided to departments and has been placed in the guide. The memo has proven to be a good resource for hiring managers when an applicant does not pass the background screening. HR has provided a copy of the memo to departments and Offices completing their own backgrounds as well as worked with them to evaluate their process, create any necessary procedures, and to determine appropriate hand offs to HR. 2020 Global Follow-up Report #20/21-3 November 2020 Page 15 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 17 Human Resources – New Hires 08/09- 16 3.2 It is recommended the County develop standardized “pre-adverse action disclosures” and “adverse action notices” to provide to candidates whose applications are denied, in whole or in part, on the basis of information contained within a “consumer report.” Underway Complete HR worked with County Legal to review the standardized "pre-adverse action disclosures" and "adverse action notices" for use by County HR to be in compliance. The disclosures and notices were approved and are in use by County HR. While County HR does not oversee the background screening process for Parole & Probation, the Sheriff's Office, and 9-1-1 District, HR did connect with them on best practices and appropriate hand-offs to HR. HR has coordinated with Health Services on their background screening process and all disclosures and notices are now coordinated through County HR. 2020 Global Follow-up Report #20/21-3 November 2020 Page 16 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 18 Human Resources - Span of Control 18/19-2 1 It is recommended for Human Resources to consider utilizing some performance measures for the workforce on EEOP and supervisory topics that may include but are not limited to • percentage change of EEOP disparities, • percentage female supervisors and compared to female workforce percentage, and • percentage minority supervisors compared to community workforce. Planned Complete HR has established 2 performance measures specific to DEI initiatives. Specifically, HR is tracking the % of female and minority leaders compared to the community workforce percentages and HR is tracking the % of all female and minority employees compared the community workforce percentages. 19 Human Resources - Span of Control 18/19-2 2 It is recommended for Human Resources to integrate EEOP recommendations into recruitment/promotion efforts. Underway Underway In addition to the draft interview guide and HR's increased promotion of the County's job opportunities, HR has reviewed the applicant’s life cycle to evaluate additional areas to impact the County's recruitment selection processes. This review has helped us to identify areas within the selection process to focus efforts to better align with the County's EEOP goals. Mar-21 2020 Global Follow-up Report #20/21-3 November 2020 Page 17 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 20 Light fleet manage- ment 14/15- 10 1 It is recommended the County [with the assistance of the Fleet Manager (Road)] develop a fleet management policy, obtain input from County management and departments, and secure approval of the policy from upper management/Board. Underway Complete Board Approved the Light Fleet Policy on March 11, 2020. 21 Light fleet manage- ment 14/15- 10 2 It is recommended the policy guidance include associated forms and materials anticipated to be used to control and monitor vehicle fleet decisions. Underway Complete Board Approved the Light Fleet Policy on March 11, 2020. 22 Light fleet manage- ment 14/15- 10 3 It is recommended for the County to consider policies that support increasing vehicle utilization. Underway Complete Board Approved the Light Fleet Policy on March 11, 2020. 23 Light fleet manage- ment 14/15- 10 6 It is recommended for the Road Department to consider whether it would be beneficial to further refine the way it accounts for its costs. Underway Complete This has been considered through implementation of various cost accounting software packages. 2020 Global Follow-up Report #20/21-3 November 2020 Page 18 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 24 Light fleet manage- ment 14/15- 10 7 It is recommended for the County to consider how to establish motor pools and associated charges for departments that use them. Underway Complete Board Approved the Light Fleet Policy on March 11, 2020. 25 Property & Facilities 11/12- 12 4 Based on the discussions from this year’s budget committee, it is further recommended for the County to consider an accounting and budgeting process for building usage costs to assure transparency, equity and fairness in costs and sufficiency to meet debt and future repairs. The County may also need to address in the solution the rules under OMB A-87 for cost allocations. Underway Complete After discussions with the County Administrator, Facilities Director, and Deschutes County CFO, we have decided not to change the County’s process for accounting and budgeting for building usage. Although we acknowledge several benefits from a more consistent approach, the different business and operational needs of each department and the wide variety of revenue sources supports the current practice of funding facility purchases and maintenance based on the revenue resources in each department. As debt service is retired, buildings are purchased, and repairs are budgeted, staff will continue to consider the best path forward taking into account transparency, equity and fairness in costs and sufficiency to meet debt and future repairs. 2020 Global Follow-up Report #20/21-3 November 2020 Page 19 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 26 Sheriff’s Office – Inmate Health Services 17/18-3 4 It is recommended for jail management to develop appropriate reports and analyses on services to be more effective with their services. Underway Complete With the implementation of CorrecTek several reports have been created. Currently the following reports are being reviewed to analyze services provided: 14-day assessments, nurse sick call, provider sick call, outside referrals to dentists and outside referrals for X-rays. In addition, the system allows future appointment dates to ensure all follow- ups are completed and there are no outstanding issues. 27 Sheriff’s Office – Inmate Health Services 17/18-3 6 It is recommended for the Sheriff’s Office to consider utilizing some jail medical performance measures and present this data in the County Budget to demonstrate the services they provide. Underway Complete We added two performance measures and included them in the fiscal year 19/20 and 20/21 budgets. 28 Sheriff’s Office – Inmate Health Standards 17/18-7 7 It is recommended for the Sheriff’s Office to assess whether and to what extent they want to implement some additional health standards to help them improve the services provided to inmates. Underway Underway We are continuing to work toward becoming National Commission on Correctional Health Care (NCCHC) certified. Due to COVID-19 we are not sending staff to training currently. We will assess next year to see when staff might be able to attend the necessary training. This delay has caused us to push our completion date to 2024. Mar-24 2020 Global Follow-up Report #20/21-3 November 2020 Page 20 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 29 Solid Waste 16/17-6 1 It is recommended for written procedures to be continually updated and address their changing account and control environment: identify specific controls; and identify supervision and monitoring. Underway Complete Desktop procedures have been written and are being utilized in training the new Accountant. This living document will be amended as needed in the future. 30 Solid Waste 16/17-6 7 It is recommended the Solid Waste department complete the implementation of its cost accounting system to capture all revenues and expenditures to the extent it will facilitate the needs of the department and the control efforts. Underway Complete Accounts receivable, revenues and expenses are tracked within the cost accounting system. A new import was built to bring in accounts payable expenditures from the finance system into the cost accounting system. 31 Solid Waste 16/17-6 8 It is recommended for management to periodically reconcile/compare the County Finance and internal accounting systems. Underway Complete The revenues and expenditures in the cost accounting system are regularly reconciled to the finance system. Reports were defined within the cost accounting system to assist with this process. 2020 Global Follow-up Report #20/21-3 November 2020 Page 21 Count Depart- ment Audit# Rec # Recommendation Prior or Original Status New Status New Comments New Estimated Date (Mo/Yr) 32 Solid Waste 16/17-6 11 It is recommended that management identify their needs for cost accounting information from the cost accounting system. Underway Complete Volume, revenue, and expenditure reports are available using the scale and cost accounting systems. 33 Solid Waste 16/17-6 19 It is recommended for the County to consider whether the franchise fee rate percentage is at an appropriate level as the department considers implementation of its master plan for the County. Underway Complete A cursory evaluation of the time and effort spent collecting and administering the franchise system is in line with the current 3% fee. We feel an appropriate time to reconsider this rate is when we reevaluate the tip fee. {End of Report}