Overview:
Amaka Consulting was contracted by Graham Windam Family and Children's Services (Graham Windham Inc.) to conduct Performance Improvement services. My work was essentially centered on quality assurance and performance improvement which included training and education development (TED), internal audits, internal policy writing, and incident reporting and remediation.
Graham Windham Inc.’s oversight New York State agency announced that it was planning an audit of the Graham’s services. If an organization fails an audit for the first time, the State or the funding oversight agency usually extrapolates (i.e. take money from the Agency based in the deficiency) or loses a certification on the second failure.
Project Scenario:
“As per government contract, I was contracted to assess certain processes and procedures in place at Graham Windham Inc. The auditors were due in a 2 months, and there isn’t anyone to lead organization's effort to prepare the staff for the audit. Leading this effort required knowledge of processes and documentation, as well as an understanding of and commitment to quality that AMAKA has helped implement in all other agencies. If Graham Windham fails the audit, certification cannot be achieved on the first audit, costing the organization additional resources to prepare for additional audits.
AMAKA was tasked with sketching out a plan to prepare the relevant department and the organization’s staff for the audit, with the intent to pass it the first time.”
Planning for the External Audit
The audit was announced 60 days in advance. Amaka Consulting services was contracted about 2 weeks into that timeframe. I had about 47 days to ensure all I could to assure that the client passes the audit. I began by outlining a plan to prepare the organization’s staff for the New York State audit with the intent to pass it the first time based on the project scenario above.
Revision of the requirements or expectations of the upcoming audit (Schedule: Week 3 of the receipt of the Audit's announcement. Amaka came in 2 week after the announcement!)
Review of the periods that will be audited / specific audit engagement
If the State or Federal auditors announce their coming, they usually do so along with specification of what areas of the organization's services or operations they are coming to audit. They will also indicate the period (ex. the first or second quarter) that they will be auditing. In rare cases, the auditors will announce when they are coming but will not tell the organization which specific departmental or service area or areas that they are coming to audit. The New York City agency that oversees providers of social, developmental, and mental health services engages in what it calls the Executive Order Audit (EOA). When an organization has an audit that is an EOA, the auditors can pick on anything to audit. For instance, they could see a service user sitting in the waiting area and choose to audit the interval between service user's appointment times and the time he/she spent waiting to be seen by a therapist or case manager; or audit the full range of services provided at the organization.
Involvement of key Engagement Team Members:
After ascertaining what the upcoming audit is about, the next step on my plan as the advisory service consultant of the audit preparation was to inform the various department heads and individuals who have primary stakes in the organization's success in the audit. The specifics of the external audit were shared with them with the expectations that they communicate to me any discrepancies or delinquencies that they are aware of for the period under review so that I can provide them guidance based on the applicable regulations and quality assurance expectations. Usually, this does not have to be done but only when there is an audit coming. Expectation is that employees remain in compliance all the time.
The full involvement of this team is also necessary as I engage in the following:
Planning internal (pre-external) audit: After preliminary inquiries, I found that an internal audit had not been conducted prior to the upcoming external audit. So I planned one immediately. The date and nature of the internal in-house audit was disseminated to the relevant individuals.
Conducting internal audit: For very large organizations, I would have considered, depending on the size of the facility as well as specifications of the external audit, conduct the internal review with junior associate at Amaka to help to speed up the process. For this project, I did with Graham Windham Inc.’s internal QA team. Something to look out for is whether the client organization already has the requisite tools and forms to facilitate the internal quality assurance review. In this case of Graham Windham, some forms were present and most were missing. I immediately developed a few new tools/forms, and modified some existing template that Amaka already had. Then a version of those tools were shared with managers and department heads so that they know what we will be looking for. In most instances where time could afford, Amaka Consulting would train managers or department heads to conduct their own internal reviews using the available tools.
Rectifying, and documenting delinquencies using established standards: The findings from the internal audit were communicated and documented accordingly. Statement of deficiency (SOD) was developed and plan of corrective actions (POCA) dispensed with it. The POCA provided for Crashing Approach to remediating some correctable issues and policy development or modification started alongside the actual internal audit. A system of procedure was developed and disseminated organization-wide to guide against future discrepancies of the types that were found during the internal audit. Staff training developed, for the types of training that weren't available if not already existing, to train staff on the policy, expectations, or protocol.
Preliminary Engagement Activities:
Performing procedures required by regulations: In addition to review of the documentation and practices surrounding their completion, I ensured that evidence existed that all of the services, policy, and procedures were compliant with State/Federal regulations.
In addition to these, I will also:
Evaluate compliance with relevant ethical requirements in accordance with regulations:
Training & Education: Help managers and department heads to establish an understanding of the terms of the engagement and expectations of the regulations. The managers are expected to train their staff in a timely fashion.
Planning post-internal review and pre-external audit activities:
Highlighting the scope, timing and expectations of the external audit as we anticipated the auditors
Educated managers and department heads of the characteristics of the engagement that defined the scope of the upcoming audit
Ascertained the reporting objectives of the external audit, the nature of communication as well as any other professional, legal and regulatory expectations that the auditors may have.
Documentation: In the compliance arena, what is not documented is never done or at least as the notion goes. Therefore, all efforts will be documented as per regulations.