REPORT DIGEST UNIVERSITY OF ILLINOIS COMPLIANCE EXAMINATION FOR THE YEAR ENDED JUNE 30, 2021 Release Date: June 29, 2022 FINDINGS THIS AUDIT: 23 CATEGORY: NEW -- REPEAT – TOTAL Category 1: 3 -- 1 -- 4 Category 2: 9 -- 10 -- 19 Category 3: 0 -- 0 -- 0 TOTAL: 12 -- 11 -- 23 FINDINGS LAST AUDIT: 19 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 INTRODUCTION This digest covers our State Compliance Examination of the University of Illinois for the year ended June 30, 2021. A separate Financial Audit as of and for the year ended June 30, 2021 was previously released on May 18, 2022. A separate Single Audit for the year ended June 30, 2021 was previously released on June 8, 2022. In total, this report contains 23 findings, 13 of which were reported in the Financial Audit and Single Audit. SYNOPSIS • (21-14) The University of Illinois Hospital was unable to provide adequate records substantiating written notices were provided to patients within 24 hours after their admittance into the University Hospital indicating the patients were under observation status in accordance with the University of Illinois Hospital Act and University policies and procedures. • (21-16) The University did not comply with the requirements of the Illinois Health Policy Center Act. • (21-20) The University did not ensure employees completed their initial ethics and sexual harassment training in accordance with the requirements of the State Officials and Employees Ethics Act. FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS FAILURE TO MAINTAIN ADEQUATE RECORDS SUBSTANTIATING WRITTEN NOTICES The University of Illinois Hospital (University) was unable to provide adequate records substantiating written notices were provided to patients within 24 hours after their admittance into the University Hospital indicating the patients were under observation status in accordance with the University of Illinois Hospital Act (Act) and University policies and procedures. The University’s Patient Admissions Policy and Procedure (Policy) requires the University to issue Notice of Observation Status (Form UI-5010) to patients after their admittance into the University Hospital notifying them they have been placed under outpatient observation status and have not been admitted as an inpatient. In addition, the University requires patients or their legal representative to sign the Form UI-5010 to acknowledge the receipt and understanding of their outpatient observation status. In lieu of samples being selected to test compliance with this mandate, the University stipulated it was not in compliance. (Finding 14, Pages 40-41) This finding has been reported since 2017. We recommended the University strengthen its controls to ensure Notice of Observation Status forms are retained for all patients not admitted into the University Hospital, but who are under observation status and seek legislative relief for instances where the status of a patient is changed after a patient has been discharged. University officials accepted the recommendation. NONCOMPLIANCE WITH THE ILLINOIS HEALTH POLICY CENTER ACT The University of Illinois (University) did not comply with the requirements of the Illinois Health Policy Center Act (Act). As of June 30, 2021, the University had not created the Illinois Health Policy Center (Center) as required by the Act. The purpose of the Center is to develop and implement policies to improve the health and healthcare of the people of Illinois. The Illinois Health Policy Center Act (110 ILCS 430/10) requires the Illinois Health Policy Center to be created within the University of Illinois, to be sponsored by the University of Illinois at Chicago College of Medicine and the University of Illinois Institute of Government and Public Affairs. (Finding 16, Page 44) This finding has been reported since 2017. We recommended the University comply with the requirements of the Illinois Health Policy Center Act or seek legislative remedy. University officials accepted the recommendation. INADEQUATE CONTROLS OVER COMPLIANCE WITH THE STATE OFFICIALS AND EMPLOYEES ETHICS ACT The University of Illinois did not ensure employees completed their initial ethics and sexual harassment training in accordance with the requirements of the State Officials and Employees Ethics Act. During our review of 60 employees, including eight newly hired employees, required to complete ethics and sexual harassment training for the fiscal year ended June 30, 2021, we noted the following: • Three of the eight (38%) new employees did not timely complete the initial ethics training as required. Ethics trainings were completed 45-90 days late. • Three of the eight (38%) new employees did not timely complete the initial sexual harassment training as required. Sexual harassment trainings were completed 27-56 days late. • One of the eight (13%) new employees did not complete the initial sexual harassment training. (Finding 20, Page 49) We recommended the University strengthen its controls to ensure all employees complete their initial ethics and sexual harassment training in accordance with the requirements of the State Officials and Employee Ethics Act. University officials accepted the recommendation. OTHER FINDINGS The remaining findings are reportedly being given attention by the University. We will review the University’s progress towards the implementation of our recommendations in the next engagement. AUDITOR’S OPINIONS The financial audit was previously released. Our auditors stated the financial statements of the University of Illinois as of and for the year ended June 30, 2021 are fairly stated in all material respects. The single audit was previously released. Our auditors also conducted a Single Audit of the University as required by the Uniform Guidance and stated the University complied, in all material respects, with the types of compliance requirements that could have a direct and material effect on the University’s major federal programs for the year ended June 30, 2021. ACCOUNTANT’S OPINION The accountants conducted a State compliance examination of the University for the year ended June 30, 2021, as required by the Illinois State Auditing Act. The accountants qualified their report on State compliance for Findings 2021-001 through 2021-004. Except for the noncompliance described in these findings, the accountants stated the University complied, in all material respects, with the requirements described in the report. The State Compliance Examination was conducted by RSM US 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:TLK