41
i TABLE OF CONTENTS FOR AUDIT, COMPLIANCE, AND MANAGEMENT REVIEW COMMITTEE Committee Meeting: 5/12/2010 Austin, Texas R. Steven Hicks, Chairman Paul L. Foster Janiece Longoria Robert L. Stillwell Committee Meeting Page A. CONVENE 11:00 a.m. Chairman Hicks 1. U. T. System: Report on the Systemwide Compliance Work Plan for 2010 - 2011 11:00 a.m. Report/Discussion Mr. Plutko 29 2. U. T. System: Presentation on the U. T. Systemwide Endowment Compliance Program 11:10 a.m. Report Dr. Safady 33 3. U. T. System: Internal Audit Department report for U. T. Health Science Center Tyler 11:20 a.m. Report/Discussion Ms. Kris Kavasch, U. T. Health Science Center Tyler 51 4. U. T. System: Report on the Systemwide internal audit activities, including the results of the Systemwide Huron/Effort Certification and Reporting Technology (ECRT) audit 11:30 a.m. Report/Discussion Mr. Chaffin 64 B. RECESS TO EXECUTIVE SESSION PURSUANT TO TEXAS GOVERNMENT CODE, CHAPTER 551 Personnel matters relating to appointment, employment, evaluation, assignment, duties, discipline, or dismissal of officers or employees - Texas Government Code Section 551.074 U. T. System: Discussion with institutional auditors and compliance officers concerning evaluation and duties of individual System Administration and institutional employees involved in internal audit and compliance functions 11:40 a.m. Report Ms. Kris Kavasch, U. T. Health Science Center Tyler Mr. Chaffin Mr. Plutko C. RECONVENE IN OPEN SESSION TO CONSIDER ACTION, IF ANY, ON EXECUTIVE SESSION ITEM AND TO ADJOURN 12:00 p.m.

TABLE OF CONTENTS FOR AUDIT, COMPLIANCE, AND … · audit, compliance, and management review committee ... work plan for 2010 - 2011 11:00 a.m. ... compliance work plan for fiscal

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TABLE OF CONTENTS

FOR AUDIT, COMPLIANCE, AND MANAGEMENT REVIEW

COMMITTEE

Committee Meeting: 5/12/2010 Austin, Texas

R. Steven Hicks, Chairman Paul L. Foster Janiece Longoria Robert L. Stillwell

Committee Meeting Page

A. CONVENE 11:00 a.m. Chairman Hicks

1. U. T. System: Report on the Systemwide Compliance Work Plan for 2010 - 2011

11:00 a.m. Report/Discussion Mr. Plutko

29

2. U. T. System: Presentation on the U. T. Systemwide Endowment Compliance Program

11:10 a.m. Report Dr. Safady

33

3. U. T. System: Internal Audit Department report for U. T. Health Science Center – Tyler

11:20 a.m. Report/Discussion Ms. Kris Kavasch, U. T. Health Science Center – Tyler

51

4. U. T. System: Report on the Systemwide internal audit activities, including the results of the Systemwide Huron/Effort Certification and Reporting Technology (ECRT) audit

11:30 a.m. Report/Discussion Mr. Chaffin

64

B. RECESS TO EXECUTIVE SESSION PURSUANT TO TEXAS GOVERNMENT CODE, CHAPTER 551

Personnel matters relating to appointment, employment, evaluation, assignment, duties, discipline, or dismissal of officers or employees - Texas Government Code Section 551.074

U. T. System: Discussion with institutional auditors and compliance officers concerning evaluation and duties of individual System Administration and institutional employees involved in internal audit and compliance functions

11:40 a.m. Report Ms. Kris Kavasch, U. T. Health Science Center – Tyler Mr. Chaffin Mr. Plutko

C. RECONVENE IN OPEN SESSION TO CONSIDER ACTION, IF ANY, ON EXECUTIVE SESSION ITEM AND TO ADJOURN

12:00 p.m.

29

1. U. T. System: Report on the Systemwide Compliance Work Plan for 2010 - 2011

REPORT Mr. Lawrence Plutko, Systemwide Compliance Officer, will provide a status update on the Systemwide Compliance Work Plan for 2010 – 2011 set forth on Pages 30 - 32.

THE UNIVERSITY OF TEXAS SYSTEM SYSTEMWIDE COMPLIANCE OFFICE

COMPLIANCE WORK PLAN FOR FISCAL YEAR 2010-2011

Page 1

PLAN OBJECTIVES AUTHORITATIVE GUIDANCE STATUS AS OF 04/15/2010 I. RESEARCH CONFLICTS OF INTEREST

Study and make recommendations regarding policy, practice, procedures, and enforcement of the UT System institutions’ research conflicts of interest policies.

Collaborate with the Office of General Counsel and the institutions to develop a System policy with performance standards/principles that will enhance and standardize institutional compliance for research conflicts of interest.

Devise a state-of-the-art policy implementation process with standardized procedures combined with legal/compliance oversight.

National Science Foundation Public Health Services Act National Institutes of Health Office of Research Integrity Department of Justice

Analysis of institutions’ policies completed with recommendations made to the Chancellor.

Draft System policy written and transmitted to the institutions for a 75-day vetting period. The comment period is completed.

IT support plan containing options for electronic submission of disclosures completed and now being vetted at the institutions.

II. VENDOR RELATIONS Study and make recommendations regarding policy,

practice, procedures, and enforcement of the UT System institutions’ policies on vendor relations.

Collaborate with OGC to develop a System policy and guidelines to govern and offer guidance on the interactions between the institutions and personnel with vendors providing financial support for educational activities, educational materials, preceptorships, fellowships, scholarships, and other similar areas.

Anti-kickback Statute PhRMA Code on Interactions

with Healthcare Professionals OIG Program Guidance for

Pharmaceutical Manufacturers ACCME Standards for

Commercial Support

TBA – early 2011 after completion of Research Conflicts of Interest initiative.

30

THE UNIVERSITY OF TEXAS SYSTEM SYSTEMWIDE COMPLIANCE OFFICE

COMPLIANCE WORK PLAN FOR FISCAL YEAR 2010-2011

Page 2

PLAN OBJECTIVES AUTHORITATIVE GUIDANCE STATUS AS OF 04/15/2010 III. RECOVERY AUDIT CONTRACTOR

PROGRAM Collaborate with Health Affairs to develop a best

practices framework to deal with CMS Claim Review Programs with a particular focus on the Recovery Audit Contractor (RAC) Program.

Design an interdisciplinary team model to provide overall guidance and direction to oversee RAC readiness and coordinate the intricate RAC appeals process.

Medicare Prescription Drug, Improvement and Modernization Act (MMA, 2003)

Tax Relief and Health Care Act (2006)

All health institutions have developed RAC committees/teams and completed RAC readiness checklist.

Systemwide Compliance providing compliance consultation as needed.

IV. EXPORT CONTROLS COMPLIANCE Collaborate with Research and Technology Transfer

to develop a model UT System Export Controls program for the benefit of the institutions.

Department of State/ITAR Department of

Treasury/OFAC Department of

Commerce/EAR

Task Force completes draft export controls policy and Research & Tech Transfer transmits and completes vetting process at the institutions for U. T. System Policy 173.

V. CLINICAL RESEARCH BILLING COMPLIANCE Collaborate with Health Affairs to develop a model

UT System Clinical Research Billing Compliance program for the benefit of the institutions.

Conduct a compliance effectiveness review once the enhanced program is in place.

Medicare General Rules Medicare Investigational

Devices Medicare National Coverage

Determinations Medicare Secondary Payor

Rules Medicaid General Rules

Guiding Principles for Clinical Research Billing Compliance completed.

Onsite, pre-enhancement compliance reviews completed at all health institutions utilizing the Guiding Principles.

31

THE UNIVERSITY OF TEXAS SYSTEM SYSTEMWIDE COMPLIANCE OFFICE

COMPLIANCE WORK PLAN FOR FISCAL YEAR 2010-2011

Page 3

PLAN OBJECTIVES AUTHORITATIVE GUIDANCE STATUS AS OF 04/15/2010 VI. HITECH ACT HIPAA PROVISIONS

Collaborate with Health Affairs and OGC to study and prepare for the major revisions to the HIPAA Privacy and Security Rules delineated in the new provisions.

Update changes to the Notice of Privacy Practices (NOPP), standard Business Associate Agreements (BAA), and other mechanisms.

Develop a Breach Notification Policy and other policies as required.

Health Information Technology for Economic and Clinical Health Act (HITECH Act, 2009)

Plans for a series of June Systemwide Compliance Academy web conferences co-sponsored by SWC and OGC in collaboration with the HIPAA Privacy and Security Officers completed.

A parallel series is being planned for academic health centers.

VII. SYSTEMWIDE COMPLIANCE PROGRAM ENHANCEMENT Develop an action plan in collaboration with the

Institutional Compliance Officers to implement the new Systemwide Compliance Program Charter and implement the same.

Revise U. T. System Policy 119, Institutional Compliance Program.

Revise quarterly reporting to include institutional compliance effectiveness metrics and institutional work plan progress and milestones.

Compliance Charter for the Systemwide Compliance Office (2009)

U. T. System Policy 119, Institutional Compliance Program

Action plan, chartering compliance advisory committees, completed.

All institutions have completed and submitted work plans for FY 2010-2011.

Phase One revisions completed for enhanced quarterly reporting.

VIII. VIRTUAL COMPLIANCE ACADEMY Establish a web conferencing and webinar platform

to serve as an education and communication tool to vet and discuss compliance program objectives and initiatives, to provide professional development opportunities, and to sponsor compliance continuing education programs on key topics.

N/A The Compliance Academy sponsored 7 webinars with a total of over 300 registrants.

The Academy also sponsored 14 medical billing compliance webinars with over 1000 registrants.

32

33

2. U. T. System: Presentation on the U. T. Systemwide Endowment Compliance Program

REPORT Vice Chancellor Safady will report on the U. T. Systemwide Endowment Compliance Program using a PowerPoint presentation set forth on Pages 34 - 50.

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e of

0.0

8% to

0.2

% o

f the

m

arke

t val

ue o

f its

end

owm

ents

, dep

endi

ng

onel

igib

ility

on e

ligib

ility

•In

FY

09, $

7.7

milli

on in

fees

dis

tribu

ted

to

td

tt

dsu

ppor

t end

owm

ent m

anag

emen

t and

ad

min

istra

tion

15

48

Prog

ress

and

Pla

ns fo

r Im

prov

emen

t•

Inst

itutio

n re

ports

are

ana

lyze

d an

d a

man

agem

ent r

espo

nse

is re

quire

d fro

m th

e U

. T. i

nstit

utio

n•

Impl

emen

tatio

nof

man

agem

entr

espo

nse

ism

onito

red;

•Im

plem

enta

tion

of m

anag

emen

t res

pons

e is

mon

itore

d;

incr

ease

d ac

coun

tabi

lity

has

resu

lted

in im

prov

emen

t in

mos

t rep

ort c

ateg

orie

s•

Beg

inni

ng in

FY

10, a

ll en

dow

men

ts w

ill be

revi

ewed

at l

east

ev

ery

3 ye

ars

•Im

prov

emen

tto

the

track

ing

ofin

stitu

tion

prog

ress

•Im

prov

emen

t to

the

track

ing

of in

stitu

tion

prog

ress

•In

clus

ion

of a

“Rep

ort o

f Use

” let

ter w

ith a

ll en

dow

men

t do

nor r

epor

tsp

•E

nhan

cem

ent o

f the

dat

abas

e to

refin

e re

porti

ng a

nd

anal

ysis

cap

abili

ties

16

49

Con

clus

ions

•P

rogr

am c

ontin

ues

to id

entif

y ris

ks a

nd

incr

ease

com

plia

nce

p•

Inst

itutio

ns c

ontin

ue to

mon

itor m

ore

endo

wm

ents

each

year

endo

wm

ents

eac

h ye

ar•

Dat

a ga

ther

ed e

ach

year

con

tinue

s to

iden

tify

trend

stre

nds

•A

naly

sis

prov

ides

abi

lity

to re

vers

e or

pre

vent

ti

td

nega

tive

trend

s•

Que

stio

ns?

17

50

51

3. U. T. System: Internal Audit Department report for U. T. Health Science Center – Tyler

REPORT Using a PowerPoint presentation set forth on Pages 52 - 63, Ms. Kris Kavasch, Director of Internal Audit, U. T. Health Science Center – Tyler, will make a presentation on how audit coverage is achieved at a small institution.

Ms.

Kris

Kav

asch

, Dire

ctor

Offi

ce o

f Int

erna

l Aud

it

U. T

. Sys

tem

Boa

rd o

f Reg

ents

’ Mee

ting

Aud

it, C

ompl

ianc

e, a

nd M

anag

emen

t Rev

iew

Com

mitt

eeM

ay20

10M

ay 2

010

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

52

Inte

rnal

Aud

it C

omm

ittee

Inte

rnal

Mem

bers

Dr.

Kirk

A. C

alho

un, P

resi

dent

and

Cha

irman

Dr.

Dav

id C

oulta

s, V

ice

Pre

side

nt fo

r Clin

ical

Affa

irs a

nd P

hysi

cian

-In-C

hief

Dr.

Ste

ven

Idel

l, V

ice

Pre

side

nt fo

r Res

earc

hM

r. V

erno

n M

oore

, Vic

e P

resi

dent

and

Chi

ef B

usin

ess

and

Fina

nce

Offi

cer

Mr.

Rob

Mar

shal

l, V

ice

Pre

side

nt a

nd C

hief

Ope

ratin

g O

ffice

r M

r. M

ac G

riffit

h, V

ice

Pre

side

nt a

nd C

hief

Dev

elop

men

t Offi

cer

MG

Did

Hll

Ad

ii

tti

Di

tB

iO

tiM

r. G

. Dav

id H

ullu

m, A

dmin

istra

tive

Dire

ctor

, Bus

ines

s O

pera

tions

Mr.

Joe

Woe

lker

s, E

xecu

tive

Dire

ctor

, Aca

dem

ic A

ffairs

Ms.

Don

na M

artin

, Dire

ctor

of C

ompl

ianc

e an

d In

form

atio

n S

ecur

ity O

ffice

r

Ext

erna

l Mem

bers

Mr.

Jeff

Aus

tin II

I, V

ice

Cha

irman

, Aus

tin B

ank

Mr.

Ken

Fin

dley

, Atto

rney

at L

aw, F

indl

ey L

aw F

irm

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

Mee

ts q

uarte

rly w

ith la

st m

eetin

g he

ld o

n M

arch

19,

201

02

53

Inte

rnal

Aud

it D

epar

tmen

t Sta

ffing

pg

Dep

artm

ent c

ompo

sitio

n:

Ms.

Kris

Kav

asch

, CP

A, C

FE, D

irect

orM

s. G

ail L

ewis

, CP

A, C

IA, S

uper

viso

rM

r. D

onal

d H

enry

, CG

AP

, Int

erna

l Aud

itor

y,,

Aud

itre

ports

issu

ed:A

vera

ge10

pery

ear

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

Aud

it re

ports

issu

ed: A

vera

ge 1

0 pe

r yea

r3

54

Inte

rnal

Aud

itR

epor

ting

Stru

ctur

eIn

tern

al A

udit

Rep

ortin

g St

ruct

ure

Dire

ctor

of I

nter

nal A

udit

repo

rts fu

nctio

nally

to

both

the

pres

iden

t and

the

Inte

rnal

Aud

it C

omm

ittee

Com

mitt

ee

Di

tfI

tlA

dit

td

ii

tti

lD

irect

or o

f Int

erna

l Aud

it re

ports

adm

inis

trativ

ely

to th

e pr

esid

ent

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

4

55

Hig

h R

isk

Are

as to

be

Aud

ited

in F

Y 20

1064

% o

f the

inte

rnal

aud

it ac

tiviti

es p

lann

ed fo

r FY

20

10 a

re m

appe

d to

hig

h ris

k ar

eas

iden

tifie

d in

the

follo

win

gca

tego

ries:

follo

win

g ca

tego

ries:

Cat

egor

yPe

rcen

tage

of P

lan

Fina

ncia

l25

%Fi

nanc

ial

25%

Ope

ratio

nal

18%

Com

plia

nce

17%

Info

rmat

ion

Tech

nolo

gy13

%A

udit

Follo

w-U

p4%

Proj

ects

–A

udit,

23

% FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

j,

Con

sulti

ng, &

Oth

er23

%

5

56

Qua

lity

Ass

uran

ce R

evie

wM

ostr

ecen

text

erna

lqua

lity

assu

ranc

ere

view

repo

rtw

asis

sued

Mos

t rec

ent e

xter

nal q

ualit

y as

sura

nce

revi

ew re

port

was

issu

ed

in O

ctob

er 2

009

Res

ult:

“Gen

eral

ly c

onfo

rms”

in a

ll m

ater

ial r

espe

cts

to In

stitu

te

ofIn

tern

alA

udito

rsS

tand

ards

and

Cod

eof

Eth

ics

of In

tern

al A

udito

rs S

tand

ards

and

Cod

e of

Eth

ics

Opp

ortu

nitie

s fo

r im

prov

emen

t ide

ntifi

ed in

the

area

s of

:O

rient

atio

n of

ext

erna

l mem

bers

of t

he In

tern

al A

udit

Com

mitt

ee

Ris

kba

sed

audi

tcom

plet

ion

Ris

k ba

sed

audi

t com

plet

ion

Info

rmat

ion

tech

nolo

gy a

udit

cove

rage

Com

mun

icat

ing

audi

t res

ults

Inte

rnal

qual

ityas

sura

nce

prog

ram

Inte

rnal

qua

lity

assu

ranc

e pr

ogra

mG

ener

ally

Acc

epte

d G

over

nmen

tal A

uditi

ng S

tand

ards

com

plia

nce

All

reco

mm

enda

tions

hav

e be

en a

ddre

ssed

by

the

orig

inal

im

plem

enta

tion

date

s

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

impl

emen

tatio

n da

tes

6

57

U. T

. Sys

tem

and

U. T

. Ins

titut

ion

Part

ners

hips

•Lim

ited

num

ber

of a

vaila

ble

staf

f ho

urs

and

IT

audi

t exp

ertis

e at

U

THSC

T

Iden

tifie

d St

reng

ths:

Syst

em

•Aud

it ex

pert

ise

in IT

and

oth

er

subj

ect m

atte

rs• A

bilit

y to

mat

ch

Rec

urrin

g O

ppor

tuni

ty:

Syst

em

Aud

it O

ffice

yst

reng

ths

and

oppo

rtun

ities

ac

ross

U. T

. in

stitu

tions

th

roug

h an

i

htl

Solu

tion:

Smal

l U. T

. In

stitu

tions

over

sigh

t rol

e

Two

Syst

em

Aud

it O

ffice

In

itiat

ives

•Sub

ject

Mat

ter

Expe

rt E

xcha

nge

Prog

ram

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

g•I

T A

udit

Exch

ange

Pr

ogra

m7

58

UTH

SCT

and

U. T

. Sys

tem

Exa

mpl

eA

td

b•T

wo

IT a

udits

on

UTH

SCT

FY 2

010

audi

t pla

n:•I

T G

over

nanc

e•T

exas

Adm

inis

trat

ive

Cod

e §

202

U. T

. Sy

stem

St

reng

th:

•Aug

men

ted

by

stra

tegi

c as

sign

men

t of a

n IT

Aud

it M

anag

er

as th

e Sy

stem

A

udit

Offi

ce

UTH

SCT

Opp

ortu

nity

: IT

audi

t

IT a

udit

man

ager

s on

team

Aud

it O

ffice

lia

ison

to

UTH

SCT

Solu

tion:

Sy

stem

Aud

it O

ffi

IT a

udit

expe

rtis

e st

ill b

eing

de

velo

ped

Offi

ce

dedi

cate

s IT

au

dit o

vers

ight

ho

urs

in F

Y 20

10 a

udit

plan

•Goa

l is

to a

ssis

t U

THSC

T in

ad

dres

sing

its

hi

hi

kd

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

phi

gh ri

sks

and

mee

ting

IT a

udit

requ

irem

ents

8

59

UTH

SCT

IT G

over

nanc

e A

udit

Cas

e St

udy

•C

ontr

ibut

es in

stitu

tiona

l kn

owle

dge

to a

udit

U. T

. Sy

stem

•C

ontr

ibut

es IT

te

chni

cal

know

ledg

e to

UTH

SCT

Inte

rnal

A

udit

IT A

udit

Man

ager

audi

t

Res

ult:

U. T

. Sy

stem

IT A

udit

M&

Aud

it D

irect

or

Man

ager

&

UTH

SCT

Inte

rnal

A

udit

Dire

ctor

co

mbi

ne e

ffort

s to

con

duct

aud

it

•O

bjec

tive

is to

ass

ess

whe

ther

th

e IT

gov

erna

nce

of U

THSC

T su

stai

nsan

dsu

ppor

tsits

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

sust

ains

and

sup

port

s its

st

rate

gies

and

obj

ectiv

es

9

60

Part

ners

hip

Enha

nced

by

Tech

nolo

gy

Com

mon

aud

it do

cum

enta

tion

softw

are

that

al

low

sbo

thU

TS

yste

man

dU

THS

CT

team

allo

ws

both

U. T

. Sys

tem

and

UTH

SC

T te

am

mem

bers

to w

ork

join

tly o

n au

dit d

ocum

ent f

iles

Sec

ure

shar

ed W

eb s

ite, a

cces

sibl

e vi

a U

THS

CT

netw

ork,

allo

ws

fors

ecur

epo

stin

gU

THS

CT

netw

ork,

allo

ws

for s

ecur

e po

stin

g an

d sh

arin

g of

pro

ject

doc

umen

ts FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

10

61

Part

ners

hip

is C

ost E

ffici

ent

Cdi

tdt

tift

dh

dC

omm

on a

udit

docu

men

tatio

n so

ftwar

e an

d sh

ared

W

eb s

ite a

llow

for U

. T. S

yste

m IT

Aud

it M

anag

er to

ac

com

plis

h si

gnifi

cant

por

tion

of w

ork

from

Aus

tinp

gp

Sys

tem

Aud

it O

ffice

initi

ativ

e ca

lls fo

r ins

titut

iona

l lia

ison

s to

acc

ompl

ish

at le

ast t

wo

obje

ctiv

es w

hen

pj

trave

ling

to U

. T. i

nstit

utio

nsR

efer

ence

IT G

over

nanc

e A

udit:

U. T

. Sys

tem

IT A

udit

Mt

ld

tU

THS

CT

td

tj

it

Man

ager

tra

vele

d to

UTH

SC

T to

con

duct

sev

en jo

int

audi

t int

ervi

ews,

revi

ew p

roje

ct d

ocum

ents

on

site

, and

ac

com

plis

h th

e du

al p

urpo

se o

f atte

ndin

g th

e qu

arte

rly

itit

til

dit

ittti

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

inst

itutio

nal a

udit

com

mitt

ee m

eetin

g11

62

Ben

efits

of P

artn

ersh

ip

For U

THS

CT:

Gai

n kn

owle

dge

from

U. T

. Sys

tem

IT

Aud

it M

anag

er to

impr

ove

IT a

udit

expe

rtise

For U

. T. S

yste

m:

Inst

itutio

nal k

now

ledg

e ga

ined

du

ring

audi

t act

iviti

es im

prov

es p

erfo

rman

ce o

f S

yste

mA

udit

Offi

celia

ison

over

sigh

trol

eS

yste

m A

udit

Offi

ce li

aiso

n ov

ersi

ght r

ole

Sys

tem

wid

e:C

ost s

avin

gs b

y av

oidi

ng h

avin

g to

“buy

” IT

audi

t exp

ertis

e t

flfi

lldi

ti

td

ddi

titti

li

kto

fulfi

ll au

dit r

equi

rem

ents

and

add

ress

inst

itutio

nal r

isk

Mos

t im

port

antly

:C

apita

lize

upon

syn

ergy

ach

ieva

ble

as

The

Uni

vers

ity o

f Tex

as S

yste

m

FAR

FR

OM

OR

DIN

AR

Y. C

LOSE

TO

HO

ME.

12

63

64

4. U. T. System: Report on the Systemwide internal audit activities, including the results of the Systemwide Huron/Effort Certification and Reporting Technology (ECRT) audit

REPORT Mr. Charles Chaffin, Chief Audit Executive, will present the results of the Systemwide Huron/Effort Certification and Reporting Technology (ECRT) audit. In June 2007, after a two-year review of commercially-available systems, the U. T. System opted to purchase ECRT to assist in addressing the risks related to time and effort reporting errors at U. T. System institutions that receive grant funding for sponsored projects. To date, 10 U. T. System institutions have implemented the ECRT solution, at a cost to U. T. System Administration of approximately $2.67 million. The U. T. System Audit Office performed an implementation audit of the ECRT solution to provide manage-ment with project status, cost, and a blueprint for future ECRT and other Systemwide application implementations. Notably, the ECRT project enjoyed success in the areas of project management, executive sponsorship, and user involvement, but there may be opportunities for improvement with regard to the technical aspects of the imple-mentation, including maintaining process documentation. Mr. Chaffin will also report on the implementation status of significant audit recom-mendations. The second quarter activity report on the Implementation Status of Outstanding Significant Findings/Recommendations is set forth on Pages 65 - 66. Satisfactory progress is being made on the implementation of all significant recom-mendations. Additionally, a list of other audit reports issued by the Systemwide audit program is on Pages 67 - 68.

BACKGROUND INFORMATION Significant audit findings/recommendations are tracked by the U. T. System Audit Office. Quarterly, chief business officers provide the status of implementation, which is reviewed by the internal audit directors. A quarterly summary report is provided to the Audit, Compliance, and Management Review Committee of the U. T. System Board of Regents. Additionally, Committee members receive a detailed summary of new significant findings and related recommendations quarterly.

THE

UN

IVER

SITY

OF

TEXA

S SY

STEM

Impl

emen

tatio

n St

atus

of O

utst

andi

ng S

igni

fican

t Fin

ding

s/R

ecom

men

datio

ns

U. T

. SYS

TEM

AU

DIT

Ran

king

# o

f Si

gnifi

cant

Fi

ndin

gsR

anki

ng #

of

Sign

ifica

nt

Find

ings

2008

-01

UTA

RL

Sys

tem

Sec

urity

Aud

it1

14/

30/2

010

Sat

isfa

ctor

y20

09-0

7U

TAR

LD

igita

l Res

earc

h D

ata

Aud

it1

16/

1/20

10S

atis

fact

ory

2007

-06

UTA

US

UTS

163:

Gui

danc

e on

Effo

rt R

epor

ting

Pol

icie

s1

14/

30/2

010

Sat

isfa

ctor

y20

08-0

8U

TBU

TS16

5: P

rote

ctin

g th

e C

onfid

entia

lity

and

Inte

grity

of D

igita

l Res

earc

h D

ata

Follo

w U

p 1

14/

1/20

10S

atis

fact

ory

2009

-02

UTB

Fisc

al Y

ear 2

008

Phy

sica

l Pla

nt A

udit

10

3/1/

2010

Impl

emen

ted

2009

-02

UTB

Fisc

al Y

ear 2

008

Stu

dent

Fee

s A

udit

10

3/1/

2010

Impl

emen

ted

2009

-07

UTD

Uni

x1

16/

1/20

10S

atis

fact

ory

2009

-11

UTE

PFi

scal

Yea

r 200

9 A

nnua

l Fin

anci

al R

epor

t Aud

it1

13/

31/2

010

Sat

isfa

ctor

y20

09-1

2U

TEP

Texa

s A

dmin

istra

tive

Cod

e C

hapt

er 2

02 A

udit

- Pha

se 2

48/

10/2

010

Sat

isfa

ctor

y20

10-0

2U

TEP

Col

lege

of E

ngin

eerin

g - D

ean'

s O

ffice

02/

4/20

10Im

plem

ente

d20

09-0

3U

TSA

Ban

ner U

ser A

cces

s A

udit

(Sec

urity

)1

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Sat

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due

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66

Institution AuditUTAUS National College Athletic Association Football AttendanceUTAUS Change in Management - Thompson Conference CenterUTAUS Texas Education Research CenterUTAUS Information Technology Change ManagementUTAUS Cash Management and Cash Handling PolicyUTAUS Change in Management - Department of American StudiesUTAUS Change in Management - Ferguson Structural Engineering LaboratoryUTAUS Change in Management - University Interscholastic LeagueUTAUS Change in Management - Office of AdmissionsUTAUS Change in Management - Department of Human Development and Family SciencesUTAUS Texas Administrative Code, Chapter 202

UTB Fiscal Year 2009 Audit of Dual EnrollmentUTB Fiscal Year 2010 Audit of President’s Travel and Entertainment ExpensesUTB Fiscal Year 2010 Audit of Texas Workforce Commission Contract No. 2407SDF001UTB Fiscal Year 2009 Annual Financial Report AuditUTD President's Travel and EntertainmentUTD Executive EducationUTD ConstructionUTD Cash Handling and Cash ManagementUTD University Police

UTEP Student Tuition and FeesUTEP Texas Administrative Code Chapter 202 Audit - Phase 3UTEP National Hackerman Advanced Research ProgramsUTEP Technology TransferUTPA National College Athletic Association Compliance EligibilityUTPA Texas Administrative Code, Chapter 202 AuditUTSA Information Technology Organizational FundingUTSA Institutionally Managed Construction ProjectsUTTY Annual Financial Report Audit 2009 UTTY Endowment Management Fee ReviewUTTY Annual Follow-upUTTY Review of Business Continuity Plan

UTSMC - Dallas National Pediatric Infectious Disease Foundation Fiscal Year 2009 Annual Financial Report AuditUTSMC - Dallas Physical Plant Central Data and Acquisition System AuditUTSMC - Dallas Fiscal Year 2009 Financial Statement AuditUTSMC - Dallas University Hospitals Quality IndicatorsUTSMC - Dallas Expenditure Review - High Risk AreasUTSMC - Dallas Advanced Research Program GrantsUTSMC - Dallas Physician Billing Compliance

UTHSC - Houston Follow-up on Open RecommendationsUTHSC - Houston UTHSC-H Financial Statement Assurance WorkUTHSC - Houston Presidential Travel and EntertainmentUTHSC - Houston Endowment Management FeesUTHSC - Houston Texas Higher Education Coordinating Board Family Practice Residency Program Fiscal Year 2009 Annual

Financial Report AuditUTHSC - Houston Texas Higher Education Coordinating Board Obstetrics and Gynecology Residency Program Fiscal Year 2009

Annual Financial Report AuditUTHSC - Houston Texas Higher Education Coordinating Board Obstetrics and Gynecology Residency Program at LBJ Hospital

Fiscal Year 2009UTHSC - Houston Texas Higher Education Coordinating Board Internal Medicine Residency Program Fiscal Year 2009 Annual

Financial Report AuditUTHSC - Houston Texas Higher Education Coordinating Board Family Practice Preceptorship Program Fiscal Years 2008 and

2009 Annual Financial Report AuditUTHSC - Houston Follow-up on Open Recommendations

UTHSC - San Antonio Research Grants: Review of Expenditures AuditUTHSC - San Antonio Institutional Follow-UP - 1st QuarterUTHSC - San Antonio President's Office: Expenditures AuditUTHSC - San Antonio Family Practice Residency Program Audit

OTHER U. T. SYSTEM AUDIT REPORTS RECEIVED BY SYSTEM AUDIT 12/2009 through 2/2010

Information Received from Internal Audit Directors Consolidated by: System Audit OfficeMarch 2010

67

Institution Audit

OTHER U. T. SYSTEM AUDIT REPORTS RECEIVED BY SYSTEM AUDIT 12/2009 through 2/2010

UTHSC - San Antonio Institutional Follow Up: 2nd QuarterUTHSC - San Antonio Internal Medicine Primary Care Residency ProgramUTHSC - San Antonio Regional Academic Health Center Internal Medicine Primary Care Residency ProgramUTHSC - San Antonio Department of Pediatrics, Primary Care Residency ProgramUTMDACC - Houston Human Resources ComplianceUTMDACC - Houston Advanced Recovery Programs/Advanced Technology Programs

UTHSC - Tyler Fiscal Year 2009 Annual Financial Report AuditUTHSC - Tyler UTS166 Cash Management Audit - Cash Flow AnalysisUTHSC - Tyler Family Medicine Residency Program Annual Financial Report Audit Fiscal Year 2009UTSYS ADM Information Technology GovernanceUTSYS ADM Fiscal Year 2009 Annual Financial Report Consolidation Process AuditUTSYS ADM Facilities Management Departmental AuditUTSYS ADM National College Athletic Association Fiscal Year 2009 - UT El Paso UTSYS ADM National College Athletic Association Fiscal Year 2009 - UT Pan AmericanUTSYS ADM National College Athletic Association Fiscal Year 2009 - UT San AntonioUTSYS ADM National College Athletic Association Fiscal Year 2009 - UT ArlingtonUTSYS ADM National College Athletic Association Fiscal Year 2009 - UT Permian BasinUTSYS ADM Follow-up on Information TechnologyUTSYS ADM Facilities Management Operational AuditUTSYS ADM Federation Member Operating Practices AuditUTSYS ADM UT Brownsville President's Office Expenditures AuditUTSYS ADM Board of Regents Travel, Entertainment Expenses Audit

Institution AuditUTSA, UTTY, UTPB,

UTHSC -Houston, Fiscal Year 2009 Southern Association of Colleges and Schools Accreditation Financial Review

UTA, UTAUS, UTPA, UTT, UTMB, UTHSC - Houston, UTHSC - San Antonio, UTMDACC -

Houston

State of Texas Federal Portion of the Statewide Single Audit Report for the Year Ended August 31, 2009

UTAUS, UTSA, UTHSC - Houston, UTSWMC - Dallas, UT SYS ADM

State of Texas Financial Portion of the Statewide Single Audit Report for the Year Ended August 31, 2009

STATE AUDITOR'S OFFICE AUDIT REPORTS RELEASED 12/2009 THROUGH 2/2010

Information Received from Internal Audit Directors Consolidated by: System Audit OfficeMarch 2010

68