UCSD AUDIT PLAN

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UNIVERSITY OF CALIFORNIA INTERNAL AUDIT PLAN 2000-01 NARRATIVE & ASSUMPTIONS UCSD

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1.  Available Hours— Considering our historical vacancy rate, the budget is based on a staff of 13 FTE for the year. We have just recruited for the programmer analyst position and decided not to fill the vacant Auditor IV position. The salary savings will be used for an equity increase for those auditors and audit managers whose salary falls below the average salary range for their classification and auditing experience.

  “Other Resources” are not included in the plan at this time. However, if open positions remain vacant longer than anticipated, we will continue to contract with a local CPA firm for audit services on an as needed basis.   2.   Indirect Hours — Indirect hours are comparable to staff allocations for vacation and projected sick leave based on actual annual accrual amounts. Controllable indirect hours are based on 80 hours of training per employee and a minimum amount of administrative time.

While the Director has more time allocated to administrative activities than other staff, the majority of her time is allocated to direct audit activities.   3.   Audit Program— Our plan includes 100% coverage of the top 10 highest risk rated areas and 85% coverage of the next 10 highest risk ranked areas for the campus and the hospital. The majority of the coverage of high-risk areas is scheduled in the form of traditional audits.

We have planned 2,335 hours, or 10% of direct hours, in Supplemental Audits. This figure is well under the percentage spent for the first half of 1999/2000 fiscal year. While our campus typically receives a considerable number of audits requested by management during the year, we hope to use these hours to cover the index areas that have received relatively high risk rankings, but which have not been included in our plan due to resource constraints.

4. Advisory Services— Time in advisory services was allocated based on past experience and expectations for the coming year. The largest percent of time in this category is devoted to External Audit Coordination. The hours in these categories were allocated based on historical patterns.   5.   Investigations— Hours allocated to this category are based on current and past trends. They will be affected by the level of activity of theHotline which will start a second year of operation as of 7/1/2000.

6.  Support Activities— Support activity time is based on historical data.

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Total Direct Hours & Percent— Direct hours planned are 85% of net available hours for the fiscal year and are broken down as follows: ·   51% of net available hours are dedicated for the Audit Program; ·   18% for advisory services; ·   11% for investigations; and ·   5% for audit support activities.   Time Phasing Assumptions— Quarterly scheduling variances were projected based on historical analysis of indirect and direct data, as well as a future analysis based on our plans for the coming year.

Other Matters— The biggest variable that will drive our ability to complete the annual plan is the stability of our staffing level. In the past, we have had considerableturnover which has affected productivity.

FY2001

April 14, 2000

Budget

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN GENERAL CAMPUS Audit Index Tier 2/3 Audit Area / Audit Name CARRY FORWARD PROJECTS 00-47 H.e.03 University Extension 80 Audit Name: UC Connect   (ESPP) Audit Description: The purpose of this audit will be to perform the second phase of a review of the UC Connect Program managed and operated by the UCSD Extended Studies and Public Programs (ESPP). The first phase of the review consisted of business transactional process in the business office, i.e., personnel, payroll, timekeeping, procurement, entertainment, travel, etc. This second phase of the review will focus on the programmatic aspects, and has been deferred until such time as the executive director has been named. The purpose and timing of this review will be to provide an objective evaluation of management oversight for programmatic efforts as a service to the incoming executive director. 00-69 C.a.04 Environment Health & Safety 100 Audit Name: EH&S Audit Description: The purpose of this limited scope review will be to assist EH&S with a review of procedures and processes in place to manage, monitor, and document activities related to the radiation safety program at UCSD. The review will include a broad overview of EHS management oversight for the radiation safety program on campus and in the healthcare enterprise. The initial scope will include safety program planning and implementation. The scope of the review will also include processes employed for the procurement of radio isotopes. Information compiled during the preliminary survey will also be used during a broader review of EH&S safety programs to be performed in FY2001. 00-72 D.b.02 Project/Contract Management   (Major) 100 Audit Name: Major Capital Construction Audit Description: The purpose of this audit will be to perform a review of campus processes for project and contract management related to Major Construction Projects including roles played by campus units (FD&C, Budget Office, Purchasing, School of Engineering, etc.) and contracted parties (architects, engineers, project managers, etc.). A consultant may be engaged for purposes of providing expertise in construction auditing. The detailed scope of the review will include an assessment of project management for one project, and may include: the selection process for project management and/or consultants, contracting methodologies, funding (budget) issues, construction scheduling, etc. NEW PLANNED CAMPUS AUDIT PROJECTS 01-## C.a.04 Safety Programs 200 Audit Name: Safety Programs Audit Description: The purpose of this audit will be to perform a review of the design and implementation of UCSD Safety Programs, i.e.,radiation safety. The scope of the review will include the design and oversight role of EH&S, as well as site-specific programs at both campus and medical center locations. The review will also include follow-up activities taken to address concerns raised during prior internal/external reviews.

FY2001

April 14, 2000

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN GENERAL CAMPUS Audit Index Tier 2/3 Audit Area / Audit Name Budget 01-## H.b.02 Post Award 300 Audit Name: Contract & Grant Post Award Audit Description: The purpose of this audit will be to review campus processes for post award activity. The scope of the review will include services provided by the Office of Contract & Grant Administration, and BFS Extramural Funds Division, in financial and administrative support provided to campus departments after awards have been executed. A sample of closed awards will be selected for a detailed review of post award activity through the award closing process.

01-## E.h.03 Low Value/Purchase Order Cards 200 Audit Name: Express Card Audit Description: The purpose of this audit will be to review campus practices in the administration of the Express Card Program. The scope of the review will include central and departmental oversight of purchasing activity, as well as a detailed review of a sample of Express Card transactions. ACL will be used for purposes of statistical analysis of all transactions for a select period, as well as selecting the sample of transactions for review. The survey will also include consideration of the extent to which Express Cards may be in use by departments for business conducted via electronic commerce.

01-## G.c.02 User Authentication and Access - Central 200 Audit Name: Campus Network Security Audit Description: The purpose of this audit will be to review the campus organizational structure and program designated for maintaining security for the campus network, with an emphasis on evaluating the structure and whether resources deployed for maintaining network security have been optimized. The scope of the review will include the roles of Administrative Computing & Telecommunications, Academic Computing Services, and various campus committees.

01-## D.b.02 Project/Contract Management  (Major) 200 Audit Name: Construction Pre-Award Audit Description: The purpose of this audit will be to perform a review of campus processes for project and contract management related to Major Construction Projects including roles played by campus units (FD&C, Budget Office, Purchasing, School of Engineering, etc.) and contracted parties (architects, engineers, project managers, etc). The detailed scope of the review will include an assessment of project management for the Natural Sciences Building, and will focus on pre-award activities.

01-## D.b.02 Project/Contract Management  (Major) 200 Audit Name: Construction in Progress Audit Description: The purpose of this audit will be to perform a review of campus processes for project and contract management related to Major Construction Projects including roles played by campus units (FD&C, Budget Office, Purchasing, School of Engineering, etc.) and contracted parties (architects, engineers, project managers, etc). The detailed scope of the review will include an assessment of project management for the Basic Science Building, and will focus on construction activities.

FY2001

April 14, 2000

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN GENERAL CAMPUS Audit Index Tier 2/3 Audit Area / Audit Name Budget 01-## E.k.04 Effort Reporting 200 Audit Name: Effort Reporting (PARS) Audit Description: The purpose of this audit will be to review campus systems and processes for reporting level of effort expended on extramurally sponsored projects. The emphasis of the review will be on the adequacy of current reporting systems capability to provide accurate financial reporting, and to mitigate exposure affiliated with reviews by research sponsors, e.g., federal agencies.

01-## A.a.07 Parking 200 Audit Name: Parking & Transportation Audit Description: The purpose of this audit will be to review services provided by the Office of Parking & Transportation for purposes of meeting growing needs in the area of parking. Based on results of the preliminary survey, the detailed scope of the review may include planning & construction for new parking projects, enforcement and citation adjudication, cash receipts and related accounting, etc. The scope of the review will include services provided for both the campus and medical center communities.

01-## E.b.01 Billings and Receivables 200 Audit Name: Billings and Receivables (Non-student) Audit Description: The purpose of this audit will be to review campus administration ofaccounts receivable for non-student accounts. The scope of the review will include local policy and practice,s systems (ISIS) considerations, adequacy of services for campus constituents, etc. Based on results of the preliminary survey, the scope may include a detailed review of Accounts Receivable data via specialized audit application software (ACL).

01-## F.b.04 Recruitment & Staffing 200 Audit Name: Recruitment & Staffing Audit Description: The purpose of this audit will be to perform an overview of Human Resource practices in the area of recruitment and staffing. Based on results of the preliminary survey, the scope may include assistance in application processing (including paper andResumix), the reclass process, internal promotion equity, employee compensation versus private sector, adequacy of staff to perform tasks, exigent circumstances, performance evaluation process, merit equity and morale, organization and categorization of competent and oriented staffs, etc.

01-## G.d.01 General Controls/Data Center Operations 200 Audit Name: Academic Computing Services Audit Description: The purpose of this audit will be to perform an overview of services provided by Academic Computing Services (ACS) with an emphasis an determining whether academic community needs in the area of central information systems for academic computing are being met. The scope of the review will consist of all services provided by Academic Computing Services with the exception of campus network security which will be reviewed under a separate project number in FY2001.

FY2001

April 14, 2000

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN GENERAL CAMPUS Audit Index Tier 2/3 Audit Area / Audit Name Budget 01-## A.a.4 Housing 200 Audit Name: Housing Services Audit Description: The purpose of this audit will be to perform an overview of services provided by Housing Services. The emphasis will be on determining whether student needs in the area of campus housing are currently being met, and whether adequate plans have been developed to meet the growing need in this area based on projections for future student populations. The preliminary survey will include a comparison of projected student populations and projected available space including planned construction. The Campus Planning Office will also be consulted to ensure that projected student populations, and housing to be constructed, is based on the latest available data.

01-## G.g.02 Software – Database Review 200 Audit Name: IFIS Conversion Audit Description: The purpose of this project will be to perform a post-implementation review of campus processes for converting the Integrated Financial Information Systems (IFIS) data from the DBMS database platform to DB2. The conversion is expected to be completed in December, 2000, so the review will take place in the last half of the fiscal year   .   The scope of the review will consist of evaluating the adequacy of the migration process, and management oversight provided by Administrative Computing and Telecommunications (ACT).

01-## H.f.00.01 Student Affairs 200 Audit Name: Student Affairs Outreach Programs Audit Description: The purpose of this project will be to perform a detailed review of one or more Student Outreach efforts under the Vice Chancellor, Student Affairs, as part of the campus portfolio of outreach programs. The detailed scope of the review will be determined based on the preliminary survey completed as a supplemental review in FY2000.

01-## H.f.00.02 Student Affairs 200 Audit Name: Student Affairs Program Oversight Audit Description: The purpose of this project will be to perform a review ofVice-Chancellor oversight for Student Affairs programs (other than Associated Students and Student Cooperatives). The preliminary survey will include development of an inventory of Student Affairs programs, a comparison of programs and organizational structure with other UC campuses, and selection of one or more programs to review in detail. The detailed portion of the review may include hiring activities, scheduling, payroll and timekeeping, procurement, equipment management, etc.

01-## G.g.01 Software – Application Review 300 Audit Name: Student Link Audit Description: The purpose of this project will be to review one centralized campus software application, Student Link. The scope of the review will include an evaluation of the application's functionality, security controls,system interfaces, maintenance and change control. Criteria developed for Internet-based applications during the FY2000 review of Generic Link will be used for this review as determined applicable.

FY2001

April 14, 2000

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN GENERAL CAMPUS Audit Index Tier 2/3 Audit Area / Audit Name Budget 01-## H.f.00.03 Colleges 200 Audit Name: Marshall College Administrative Review Audit Description: The purpose of this project will be to perform a high-level review of the Marshall College Administrative functions, with an emphasis on determining whether the organizational structure and reporting relationships provide for adequate management control and accountability for programmatic and financial results. The detailed portion of the review may include hiring activities, scheduling, payroll and timekeeping, procurement, equipment management, etc.

01-## A.b.04 Fleet Management 200 Audit Name: Fleet Management Audit Description: The purpose of this audit will be to perform an overview of fleet services provided by Campus Fleet Services. Based on results of the preliminary survey, the scope of the review may include vehicle procurement, maintenance schedules, campus lease programs (versus commercial availability), shuttle services, liability coverage, recharge activity, and documentation of business use.

01-## H.c.00.13 Physics 200 Audit Name: Department of Physics Audit Description: The purpose of this project is to perform an overall assessment of the department's internal control environment, and on a test basis, an evaluation of the effectiveness and efficiency of departmental operations. Subject to results of the preliminary survey, the scope may include contract and grant activities, payroll, personnel, timekeeping, physical security for assets, equipment management, travel, entertainment, purchasing, check requests, recharge activities (potentially including development of departmental overhead rates), management and financial reporting.

01-## H.c.00.15 Psychology 200 Audit Name: Department of Psychology Audit Description: The purpose of this project is to perform an overall assessment of the department's internal control environment, and on a test basis, an evaluation of the effectiveness and efficiency of departmental operations. Subject to results of the preliminary survey, the scope may include contract and grant activities, payroll, personnel, timekeeping, physical security for assets, equipment management, travel, entertainment, purchasing, check requests, recharge activities (potentially including development of departmental overhead rates), management and financial reporting.

01-## H.c.00.26 SIO South Campus 200 Audit Name: SIO South Campus Audit Description: The purpose of this project is to perform an overall assessment of the internal control environment of the business office for south campus SIO divisions, and on a test basis, an evaluation of the effectiveness and efficiency of operations. Subject to results of the preliminary survey, the scope may include contract and grant activities, payroll, personnel, timekeeping, physical security for assets, equipment management, travel, entertainment, purchasing, check requests, recharge activities (potentially including development of departmental overhead rates), management and financial reporting.

FY2001

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN HEALTH SCIENCES Audit Index Tier 2/3 Audit Area / Audit Name CARRY FORWARD PROJECTS

April 14, 2000

Budget

00-59 I.e.01 Hospital Billing Processes 100 Audit Description: The purpose of this project will be to perform a review the hospital billing processes for patient charges. The scope of the preliminary survey will include an assessment of internal controls in the Medical Center Finance Department for billing patient fees. Based on results of the survey, the detailed scope of the review may include controls over DRG assignment to inpatient stays, an overall assessment of the encoder system, abstracting processes, and tests of supporting documentation. 00-58 I.a.0.1 Outpatient Registration 100 Audit Description: The purpose of this project will be to review the patient intake process prior to presenting in the clinic or ancillary service center. The preliminary survey will initially consist of the identification of outpatient registration sites and identity of registrars. High-level assessment of key processes, UCSD departments, and related responsibilities will be assessed.

00-57 I.k.03 Medical Group  Physician Receivables 100 Audit Description: The purpose of this review will be to assess Medical Group processes for the billing of professional physician services. In coordination with the Beacon Group report, the detailed scope of the review may include analysis of specific functions i.e.: the cash posting process, analysis of claim denials, review of the aged AR for specific departments, and analysis of the claims follow-up processes. NEW HEALTH SCIENCES AUDIT PROJECTS

01-## I.k.01 Third Party Payors Audit Name: Hospital Receivables

200

Audit Description: The purpose of this project will be to perform a review of hospital Patient Accounting Accounts Receivable Processes. Based on the results of the preliminary survey, specific audit objectives could include evaluation of credit balance resolution, evaluation of chargemaster controls and the efficacy of the Stockkamp and Associates TRAC system software (a transaction tracking system used to monitor account resolution progress).

01-## I.f.00.13 SOM – Departments 250 Audit Name: Department of Surgery Audit Description: The purpose of this project will be to perform a review of two divisions of the Surgery Department. The scope of the review will consist of a risk-based review of operations with the objective to evaluate whether controls provide a reasonable assurance that financial results are accurately reported, operations are effective and efficient, and activities are compliant with relevant policies & procedures. Based on results of the survey, testing may be performed in the following areas: contract and grant activities (including service agreements with outside parties), transaction processing (payroll, purchasing, academic recruiting, resident and fellowship programs, recharge activities), clinical trials, and professional fee billing processes and accounts receivable.

FY2001

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN HEALTH SCIENCES Audit Index Tier 2/3 Audit Area / Audit Name

April 14, 2000

Budget

01-## I.i.02 Medical Services 300 Audit Name: Department of Nursing Audit Description: The purpose of this review will be to perform a review of the Nursing Department. The scope of the review will consist of a risk-based review of operations with the objective to evaluate whether controls provide a reasonable assurance that financial results are accurately reported, operations are effective and efficient, and activities are compliant with relevant policies & procedures. Based on results of the survey, testing may be performed in the following areas: scheduling and contract labor issues, recruitment and retention, work time accountability, and medical record documentation standards. 01-## I.a.01 Admissions, Registration, and Scheduling 250 Audit Name: Registration Processes Audit Description: The purpose of this review will be to perform an assessment of additional aspects of the enterprise registration functions as a follow-up to AMAS Project #00-58, Outpatient Registration. Based on additional information needs of the management Registration team, the specific objectives of this review could include review of insurance verification and authorization processes, changes to the registration processes created by the shift to encounter based billing, and evaluation of registration controls at various Medical Group sites. 01-## E.e.01 Disbursements 200 Audit Name: Accounts Payable Audit Description: The purpose of this review is to evaluate the adequacy of controls in the accounts payable process. Specific audit objectives may include review of the check-write system process, review of sales tax and shipping charges, evaluation of compliance with purchase approval processes and monitoring of blanket purchase order activities. 01-## I.b.06 Tissue Bank 200 Audit Name: Tissue Bank Audit Description: The purpose of this project will be to perform a review of Tissue Bank operations and governing regulations. The scope of the review will include an evaluation as to whether operations are effective and efficient, and whether activities are in compliance with relevant UCSD policies and procedures and regulatory requirements. The scope of the project will also include a review and analysis of business agreements with outside agencies, and tissue acquisition and distribution procedures.

01-## H.e.00.01 Programs Audit Name: Body Donation Program

200

FY2001

April 14, 2000

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN HEALTH SCIENCES Audit Index Tier 2/3 Audit Area / Audit Name Budget Audit Description: The purpose of this audit will be to perform a review of the SOM Body Donation Program operations and governing regulations. The scope of the review will include an evaluation as to whether program operations are efficient and effective, and whether activities are in compliance with relevant UCSD policies and procedures and regulatory requirements. Based on the results of the preliminary survey, specific audit objectives could include a review of donor recruitment and restrictions, and inventory distribution and controls.

01-## D.d.02 Maintenance 200 Audit Name: Maintenance Audit Description: The purpose of this review will be to evaluate the facilities maintenance processes at the Hillcrest and Thornton Medical Centers, and associated ancillary sites. We will include an evaluation of the deferred maintenance program, and may include a review of automated controls in the Medi Miser system as appropriate.

01-## I.h.02 Telecommunications 200 Audit Name: Data Audit Description: The purpose of this project will be to review telecommunications services. Based on the results of the preliminary survey, specific audit objectives may include review of continuity of service plans, processes for prioritizing and responding to client service requests, and planned system upgrades and maintenance.

01-## I.d.02 Compensation Plan: Income Capture/Classification 300 Audit Name: Pro Fee Charge Capture Accountability Audit Description: The purpose of this review will be to review Medical Group systems and data for analyzing charge capture processes, and the resulting effect on the accounts receivable. Up to two SOM departments will be included in the system evaluation process. An additional objective may be to evaluate the associated reports to department management and accountability for system weakness resolution.

01-## I.e.01 Compliance Program – Facility Audit Name: Hospital Billing Systems

200

Audit Description: The purpose of this review is to perform an evaluation of the current status of the hospital billing system. This may include a review of additional compliance or pre-claims submission editing application functionality based on implementation status. A post implementation of credit balance resolution may also be included in audit objectives.

01## I.f.00.02 SOM - Family and Preventive Medicine 200 Audit Name: Department of   Family and Preventive Medicine Audit Description: The purpose of this project will be to perform a review of the SOM Department. The scope of the review will consist of a risk-based review of operations with the objective to evaluate whether controls provide a reasonable assurance that financial results are accurately reported, operations are effective and efficient, and activities are compliant with relevant policies & procedures. Based on

FY2001

April 14, 2000

UNIVERSITY OF CALIFORNIA, SAN DIEGO DETAILED AUDIT PLAN HEALTH SCIENCES Audit Index Tier 2/3 Audit Area / Audit Name Budget results of the survey, testing may be performed in the following areas: contract and grant activities (including service agreements with outside parties), transaction processing (payroll, purchasing, academic recruiting, resident and fellowship programs, recharge activities), clinical trials, and professional fee billing processes and accounts receivable.

01-## I.f.00.03 SOM – Medicine 300 Audit Name: Department of Medicine Audit Description: The purpose of this project will be to perform a review of three to five divisions of the Department of Medicine. The scope of the review will consist of a risk-based review of operations with the objective to evaluate whether controls provide a reasonable assurance that financial results are accurately reported, operations are effective and efficient, and activities are compliant with relevant policies & procedures. Based on results of the survey, testing may be performed in the following areas: contract and grant activities (including service agreements with outside parties), transaction processing (payroll, purchasing, academic recruiting, resident and fellowship programs, recharge activities), clinical trials, and professional fee billing processes and accounts receivable.

01-## B.a.06 Development Audit Name: Support Groups

200

Audit Description: The purpose of this project will be to perform an analysis of data available from the State of California, Registry of Charitable Trusts to determine whether non-registered UCSD Health Sciences support groups may exist. This review is a follow-up to Internal Audits #94-05 and 99-40, Support Groups. Methodology and criteria for identifying support groups should conform to those used in project #95-04. 01-## C.a.01 EH&S Audit Name: Controlled Substances

197

Audit Description: The purpose of this review will be to evaluate internal controls over controlled substances in the hospital and clinic environments. Preliminary survey procedures will include review of purchase, storage, and security procedures. Based on the survey results, specific audit objectives could include review of OR controlled substance waste procedures and department specific processes for analyzing controlled substance usage/ patient chart documentation.

01-## E.f.01 Financial Reporting - General Ledger 200 Audit Name: Healthcare Enterprise Financial Reporting Audit Description: The purpose of this project will be to evaluate the financial reporting model for the healthcare enterprise. Examination and validation of the financial data sources and associated methodology used to consolidate financial data for the hospitals, SOM, and managed care entities will be an integral portion of this review. Specific financial data in the financial reports will be analyzed for accuracy, integrity and consistency.