REPORT DIGEST DEPARTMENT OF PUBLIC HEALTH COMPLIANCE EXAMINATION FOR THE TWO YEARS ENDED JUNE 30, 2019 Release Date: June 25, 2020 FINDINGS THIS AUDIT: 26 CATEGORY: NEW -- REPEAT -- TOTAL Category 1: 0 -- 3 -- 3 Category 2: 4 -- 19 -- 23 Category 3: 0 -- 0 -- 0 TOTAL: 4 -- 22 -- 26 FINDINGS LAST AUDIT: 28 Category 1: Findings that are material weaknesses in internal control and/or a qualification on compliance with State laws and regulations (material noncompliance). Category 2: Findings that are significant deficiencies in internal control and noncompliance with State laws and regulations. Category 3: Findings that have no internal control issues but are in noncompliance with State laws and regulations. State of Illinois, Office of the Auditor General FRANK J. MAUTINO, AUDITOR GENERAL To obtain a copy of the Report contact: Office of the Auditor General, Iles Park Plaza, 740 E. Ash Street, Springfield, IL 62703 (217) 782-6046 or TTY (888) 261-2887 This Report Digest and Full Report are also available on the worldwide web at www.auditor.illinois.gov SYNOPSIS • (19-01) The Department did not exercise adequate internal controls over State vehicles. • (19-02) The Department did not comply with provisions of the MC/DD Act. • (19-03) The Department did not maintain adequate controls over its property and related records. • (19-07) The Department did not exercise adequate controls over the approval and reporting of overtime to ensure employees’ overtime requests were properly approved and overtime worked details were timely reported. FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS INADEQUATE CONTROLS OVER THE ADMINISTRATION OF STATE VEHICLES The Illinois Department of Public Health (Department) did not exercise adequate internal controls over State vehicles. The Department’s fleet consisted of 84 vehicles at June 30, 2018 and 96 vehicles at June 30, 2019. Of those vehicles, 42 were personally assigned to employees during Fiscal Year 2018 and 38 in Fiscal Year 2019. Following are a few items noted during testing: • The Department had not performed an analysis of its automobiles to determine whether maintaining each vehicle could be justified as the most cost effective solution for the specific operational needs of the Department. The auditors analyzed the total activity of the Department’s vehicles used during Fiscal Years 2018 and 2019. The Department’s vehicles traveled between 1 and 41,791 miles during Fiscal Year 2018, and 2 and 44,596 miles during Fiscal Year 2019. • The Department did not exercise adequate controls over the personal use of State vehicles. The auditors noted the following: – Seventy-six (100%) monthly vehicle logs and vehicle use certification forms tested were not reviewed and reconciled for the determination of the fringe benefit value submitted for tax purposes. The Department only used the commuting days reflected in the certification forms to report fringe benefits. In addition, 15 of 76 (20%) monthly vehicle logs and vehicle use certification forms tested differed as to the number of commuting days the State vehicle was used, resulting in understatements of reported fringe benefit payments for tax purposes totaling $255 and $39 in Fiscal Years 2018 and Fiscal Year 2019, respectively. – Twenty-nine of 76 (38%) vehicle use certification forms tested were not submitted to the Payroll Division on the 10th of the month following the usage. The vehicle use certification forms were submitted from 12 to 27 days late. – For one of 51 (2%) employees tested who was assigned a State vehicle, the Department was unable to provide justification for the commuting miles of more than 30% of the vehicle’s total mileage. The employee had commuting miles of 588 miles or 69% of the vehicle’s total mileage during Fiscal Year 2018. • The Department did not exercise adequate control over the required annual certifications of licensure and automobile liability coverage form. Forty-nine of 91 (54%) employees tested did not have the certifications on file. Forty-two certifications pertained to Fiscal Year 2018 and seven to Fiscal Year 2019. (Finding 1, pages 13-19) This finding has been repeated since 2007. We recommended the Department perform an analysis of its automobiles, monitor the submission of accident reports, enforce vehicle maintenance schedules, enforce controls over fringe benefit reporting, review and enforce procedures over the timely filing of annual certifications of license and liability insurance, and remind staff of reporting requirements. Department officials concurred with the finding and recommendation. NONCOMPLIANCE WITH THE MC/DD ACT The Department did not comply with provisions of the MC/DD Act (Act). The Act, effective July 29, 2015, required long-term care facilities for individuals under age 22 to be known and licensed as medical complexes for the developmentally disabled under the Act instead of the Intermediate Care Facility/Individual Intellectually Disabled (ID/DD) Community Care Act. Following are a few items we noted during testing of certain provisions of the Act. • The Department implemented a procedure to conduct interim on-site reviews of large or complex construction projects at the facilities and an expedited process for emergency repairs or replacement of like equipment. However, the Department did not establish the rules for the procedure and expedited process as required. • During testing of the inspections conducted for the State license renewals of the 10 MC/DD facilities during Fiscal Year 2018 and Fiscal Year 2019, we noted the following: – Eight (80%) facilities did not provide comments or documentation within 10 days of receipt of the copy of the inspection report. – One (10%) facility was inspected by the Department more than 120 days prior to license renewal. – One (10%) facility was inspected by the Department after the renewal license had been issued. • The Administrative Code was not updated to address the requirement that each policy should include the periodic review of the use of restraints. • The Department did not develop a de- identified database of residents who have injured facility staff, facility visitors, and other residents. • The Department did not keep a continuing record of all residents determined to be identified offenders and did not report the number of identified offender residents to the General Assembly on an annual basis as required. (Finding 2, pages 20-25) We recommended the Department ensure it complies with all provisions of the Act. Department officials concurred with the finding and recommendation. PROPERTY CONTROL WEAKNESSES The Department did not maintain adequate controls over its property and related records. Following are a few items noted during testing: • Sixteen of 37 (43%) property additions tested, totaling $374,246, were recorded from eight to 90 days late. • For seven of 60 (12%) property deletions tested, totaling $135,396, the Department did not properly complete the Department of Central Management Services (CMS) Surplus Delivery Form. • Five of 60 (8%) property deletions tested, totaling $11,988, were recorded from 98 to 1,329 days late. • For the Fiscal Year 2019 C-15 Reports: – Property additions did not agree with the detailed list of additions provided by the Department. The discrepancies totaled $735,123. – Property deletions totaling $4,968,505 did not agree with the detailed list of deletions provided by the Department. The discrepancies totaled $1,018,989. – Net transfers totaling $63,744 were incorrectly reported as deletions and additions. – The property balance at June 30, 2019, totaling $15,488,649 did not agree with the balance per Department inventory listing. The discrepancy totaled $1,485,604. (Finding 2, pages 26-29) This finding has been repeated since 2013. We recommended the Department implement procedures to strengthen controls over equipment and ensure accurate recordkeeping and accountability for all State owned property is maintained. Department officials concurred with the finding and recommendation. INADEQUATE CONTROLS OVER APPROVAL AND REPORTING OF OVERTIME The Department did not exercise adequate controls over the approval and reporting of overtime to ensure employees’ overtime requests were properly approved and overtime worked details were timely reported. The Department paid $2,870,875 for nearly 68,545 hours of overtime during Fiscal Years 2018 and 2019. Based upon our review of the overtime pre-approval requests and overtime worked details, we noted the following: • For 37 of 60 (62%) employees tested, overtime pre-approval requests totaling 212 hours were not pre-approved by the supervisors. These requests were approved from one to 21 days after the overtime was worked. • Twenty of 60 (33%) employees tested had overtime pre-approval requests that exceeded the allowed maximum of 10 hours. These requests ranged from 12 to 40 hours. • Thirty of 60 (50%) employees tested worked 286 hours of overtime and did not enter the detail in the timekeeping system, eTime, within two workdays as required. The details were submitted and entered from three to 29 days after the overtime was worked. (Finding 7, pages 36-37) This finding has been repeated since 2011. We recommended the Department ensure overtime pre-approval requests are timely submitted, properly approved in advance, and documentation of pre-approval is maintained. Department officials concurred with the recommendation and finding. OTHER FINDINGS The remaining findings are reportedly being given attention by the Department. We will review the Department’s progress toward the implementation of our recommendations during our next examination. ACCOUNTANT’S OPINION The accountants conducted a compliance examination of the Department for the two years ended June 30, 2019, as required by the Illinois State Auditing Act. The auditors qualified their report on State Compliance for findings 2019-001, 2019-002, and 2019-003. Except for the noncompliance described in these findings, the auditors state the Department complied, in all material respects, with the requirements described in the report. The compliance examination was conducted by E.C. Ortiz & Co., LLP. JANE CLARK Division Director This report is transmitted in accordance with Section 3-14 of the Illinois State Auditing Act. FRANK J. MAUTINO Auditor General FJM:PH