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4. Fiscal Year 2020-21 Fourth Quarter ReportInternal Audit Department Accountability  Transparency  Integrity  Quality 215 E. McKinney St., Denton, TX 76201  (940) 349-7228 MEMORANDUM DATE: October 22, 2021 TO: Honorable Mayor and Members of the City Council FROM: Madison Rorschach, City Auditor SUBJECT: Fiscal Year 2020-21 Fourth Quarter Report FY20-21 Annual Audit Plan Status Audit Project Status – The Internal Audit Department is responsible for conducting audits to assess a variety of risks including internal control weaknesses, inefficiencies in City operations, ineffectiveness of City programs, and noncompliance with laws, regulations, and policies. Each year, an annual audit plan is approved by the City Council to establish the workload of the Internal Audit Department. The following table summarizes the status of each audit project included on the FY20-21 Annual Audit Plan at the end of the third quarter. Table 1: FY20-21 Audit Project Status As of 09/30/21 Audit Project Status Months Budgeted Month Actuals1 Overflow: Health Insurance Operations Closed 1.00 1.00 Overflow: Meter Reading & Billing: Electric & Water Utilities Closed 2.00 3.00 Utility Payment Assistance Program Closed 2.00 3.25 Municipal Court Payments Process Closed 2.00 3.00 Building Permit Processes Closed 3.00 4.00 Water System Operations: Rate Structure Closed 4.00 4.75 Water System Operations: Distribution Closed Water System Operations: Production Closed Emergency Medical Services: Ambulance Billing2 Fieldwork 4.00 TBD Payroll Administration Closed 2.00 2.75 Utility Street Cuts Closed 1.00 0.50 COVID-19 Response: Disaster Reimbursements Complete 1.00 0.25 Accounts Payable Closed 1.00 1.00 Roadway Quality Management Reporting 1.00 0.50 Police Overtime Fieldwork 1.00 NA Police Property Room: Procedures Not Started 1.00 NA Risk Assessment Reporting 2.00 NA 1 Month actuals reflect the number of months it took to complete fieldwork on the project. This is calculated from the date the project was initiated to the date first draft report was distributed to management. 2 This audit project was retitled from Emergency Medical Services: Billing & Collections during the reporting process. The scope of the audit project was not affected. P a g e | 2 Post-Audit Feedback Survey Results – Based on the three audit project reports issued during the fourth quarter of fiscal year 2020-21, the Internal Audit Department’s services were rated 5.00 out of five stars by auditee department’s staff with a 40 percent response rate. Ad-Hoc Project Updates – The Internal Audit Department completed the following Consultation projects during the fourth quarter of fiscal year 2020-21: ➢ Three Advice requests from Procurement & Compliance and Parks & Recreation. Fiscal Year End Update Internal Audit Department Annual Performance Metrics – Table 2 below is intended to provide the City Council and Internal Audit Advisory Committee with a snapshot of the Internal Audit Department’s performance over the past fiscal year. These metrics are intended to meaningfully measure the Department’s output, economy, efficiency, effectiveness, and outcomes as defined below: ➢ Output: the number of audit reports – including follow-up reviews – published during each fiscal year normalized by the number of budgeted full-time equivalent positions;3 ➢ Economy: cost per audit report published including Department salaries, audit staff professional development, and audit tool expenses; ➢ Efficiency: the percentage of new audit projects closed compared to the relevant fiscal year audit plan – this measure excludes overflow project and follow-up review closures; ➢ Effectiveness: the percentage of recommendations issued that were fully concurred – this measure excludes partial concurrence; and ➢ Outcomes: the average implementation rate for audits issued during the past three fiscal years (i.e. for FY2020-21 audits issued during FY18, FY19, & FY20) – this measure will change from year to year as follow-up reviews are performed. Table 2: Internal Audit Performance Metrics Metric FY 2018-19 FY2019-20 FY2020-21 Proposed Goal Audit Reports Published Per FTE 1.67 4.67 4.00 3.00 Audit Cost per Published Report $79,400 $25,500 $27,200 $30,000 On-Time Audit Plan Completion 25.0% 37.5% 85.7% 80.0% Recommendations Concurred 85.9% 87.2% 93.1% 90.0% Three-Year Implementation Rate NA NA 73.6% 70.0% 3 This measure has been benchmarked to other similarly sized Texas city audit shops for reference in Attachment 1. Avg. Q4 Internal Audit Service Rating: P a g e | 3 It should be noted that these metrics have not been officially adopted. These metrics and proposed goals will be discussed with the Internal Audit Advisory Committee before being formalized in the Internal Audit Procedures Manual. Annual Auditing Standards Compliance Report – As required by the Internal Audit Department’s Procedures Manual, I have completed the Fiscal Year 2020- 21 Auditing Standards Compliance Report. This report summarizes the Internal Audit Department’s compliance with Generally Accepted Government Auditing Standards including structural independence, staff ethics, independence, & competence, and project compliance. The report concludes that the Department’s quality control system as suitably designed and operating effectively during Fiscal Year 2020-21. Additional details can be reviewed in Attachment 2 of this report. Post-Audit Feedback Survey Results – In order to promote continuous improvement and facilitate communication between the Internal Audit Department and auditees, a Post-Audit Feedback Survey is distributed after each report issued during an audit project. For the twelve audit project reports4 issued during Fiscal Year 2020-21, the Department had a 41 percent average response rate to this survey. The results are summarized in Table 3: Table 3: Post-Audit Feedback Survey Results Survey Question Percent Agree or Strongly Agree Proposed Goal FY19-20 FY20-21 Clearly communicated Obj., Scope, & Timing 60% 92% 90% Professional & Constructive Approach 90% 96% 90% Responsive to Suggestions & Concerns 70% 96% 90% Made Efforts to Minimize Disruption 100% 92% 90% Added Value through Meaningful Results 70% 88% 90% Unbiased & Objective Report 60% 92% 90% Average Internal Audit Service Rating 4.00 4.79 4.25 Additional Items of Note Fraud Response Policy Adoption – On September 28, 2021, the City Council adopted the Fraud Response Policy. Prior to this policy, the City had established administrative procedures for responding and investigating fraud. The adoption of the Fraud Response policy formalized these procedures as a policy as well as requiring the Internal Audit Department to: ➢ Coordinate a city-wide fraud prevention and detection training program; ➢ Ensure an anonymous method of reporting fraud suspicions or allegations is made available to employees; and 4 Audit project reports include new audits and follow-up reviews. P a g e | 4 ➢ Develop formal procedures for receiving, tracking, and managing fraud allegations and investigations in conjunction with other members of the Investigation Committee. Adoption of the Fraud Response Policy fulfills one of the Internal Audit Department’s stated goals for fiscal year 2020-21. Attachments 1. Published Audit Report Comparison 2. Fiscal Year 2020-21 Auditing Standards Compliance Report 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Lubbock (3 FTE)Garland (5 FTE)Arlington (5 FTE)Denton (3 FTE)College Station (2 FTE)Audits per Full-Time EquivalentPublished Audit Report Comparison 2018-19 2019-20 2020-21 Effective Date: 01/26/2021 Last Updated: 09/30/2021 Auditing Standards Compliance Report Fiscal Year: ______________________ Procedure Manual Version: _____________ Risk Assessment Type: ____________ Audit Plan Ordinance: _________________ Table 1: New Audit Projects Completed (FY 2020-21) Project Issued Date Audit Lead Compliance Checklist Completed 018 Health Insurance Operations 11/10/2020 Rorschach Yes 017 Utility Meter Reading & Billing: Electric &Water Utilities 01/12/2021 Sama Yes 020 Utility Payment Assistance Program 04/06/2021 Jackson Yes 019 Municipal Court Payments 04/13/2021 Sama Yes 021 Water System Operations: Rate Structure 06/22/2021 Rorschach Yes 022 Building Permit Processes 07/20/2021 Jackson Yes 021 Water System Operations: Distribution 07/27/2021 Sama Yes 021 Water System Operations: Production 09/14/2021 Rorschach Yes 023 Payroll Administration 09/28/2021 Sama Yes The following assessment documents the standards under which the Internal Audit Department’s work was conducted for one fiscal year and verifies the effectiveness of City’s quality control program including the following critical components: ¾ Department Independence & Ethics; ¾ Audit Staff Competence; and ¾ Performance Audit Standard Compliance. Based on the results of the following review, it is my opinion that, the City of Denton Internal Audit Department’s internal quality control system was suitably designed and operating effectively to provide reasonable assurance of compliance with Government Auditing Standards for audits published during the period October 1, 2020 through September 30, 2021 Based on this assessment, necessary changes have been made to the Department’s Procedure Manual. City Auditor: ____________________________________________ Date: __________ 2020-21 2.0 Limited 21-274 10/4/2021Madison Rorschach Digitally signed by Madison Rorschach DN: dc=com, dc=cityofdenton, dc=codad, ou=Department Users and Groups, ou=General Government, ou=Internal Audit, cn=Madison Rorschach, email=Madison.Rorschach@cityofdenton.com Date: 2021.10.04 10:40:39 -05'00' Effective Date: 01/26/2021 Last Updated: 09/30/2021 The Internal Audit Department currently follows the 2018 revision of Government Auditing Standards as promulgated by the United States Government Accountability Office. This checklist was developed based on these standards, the Internal Audit Department’s Procedures Manual, and the Association of Local Government Auditor’s Peer Review Guide for Yellow Book organizations. The following assessments were conducted and used to inform the opinion issued on the cover sheet. Structural Independence The City of Denton’s Internal Audit Department is considered structurally independent as defined by GAGAS 3.56, if the department head: a. Is accountable to the head or deputy head of the gov. entity or those charged with governance; Yes b. Reports the engagement results both to the head or deputy head of the gov. entity and to those charged with governance; Yes c. Is located organizationally outside the staff or line management function of the unit under audit Yes d. Has access to those charged with governance; and Yes e. Is sufficiently removed from pressures to conduct engagements and report findings, opinions, and conclusions objectively without fear of reprisal. Yes Audit Staff & Ethical Principles Table 2 summarizes the Audit staff employed during the year as well as their completion of the required Annual Ethics Pledge Form for this fiscal year: Table 2: Internal Audit Staff & Annual Ethics Pledge Summary Staff Member Title Start Date Ethics Pledge Completion Date Madison Rorschach City Auditor 01/02/2019 01/22/2021 Neeraj Sama Senior Auditor 06/24/2019 01/21/2021 Amber Jackson Senior Auditor 12/14/2020 01/21/2021 Effective Date: 01/26/2021 Last Updated: 09/30/2021 Project Independence & Competence Evaluation Independence Evaluations are completed separately by each auditor assigned to each audit project and include an evaluation of previous non-audit services performed. Competence evaluations are completed by the City Auditor for each audit project and are based on staff previous experience and Continuing Professional Education Compliance Reports. Table 3 shows which auditors completed independence assessments for each project and whether a competence evaluation was completed. Table 3: Independence & Competence Evaluations for each Project (FY 20-21) Project Evaluations Completed Independence Competence 018 Health Insurance Operations Rorschach, Sama Yes 017 Utility Meter Reading & Billing: Electric &Water Utilities Sama, Rorschach Yes 020 Utility Payment Assistance Program Jackson, Rorschach Yes 019 Municipal Court Payments Sama, Rorschach Yes 021 Water System Operations: Rate Structure Rorschach, Sama, Jackson Yes 022 Building Permit Processes Jackson, Rorschach Yes 021 Water System Operations: Distribution Rorschach, Sama, Jackson Yes 021 Water System Operations: Production Rorschach, Sama, Jackson Yes 023 Payroll Administration Sama, Rorschach Yes Effective Date: 01/26/2021 Last Updated: 09/30/2021 GAGAS Compliance Verification Of the audits completed during this fiscal year, three projects were randomly selected and reviewed to ensure GAGAS was appropriately followed and compliance was adequately documented: Water System Ops: Rate Structure Water System Ops: Production Municipal Court Payments Review of Non-Audit Projects & Legal Proceedings Yes Yes Yes Evidence of Planning Yes Yes Yes Project Risk Assessment No Yes Yes Understanding of Operations & Controls Yes Yes Yes Use of Professional Skepticism Yes Yes Yes Sufficiency & Appropriateness of Evidence Yes Yes Yes Elements of a Finding Yes Yes Yes Adequate Supervision Yes Yes Yes Objectives, Scope, & Methodology Communicated Yes Yes Yes Management Responses Yes Yes Yes Issued Report Yes Yes Yes Compliance Statement Yes Yes Yes Referenced Report Yes Yes Yes Post-Audit Feedback Survey Yes Yes Yes