Mercy Health System Audit & Compliance Committee Annual Charter Assessment

Transcription

1 Mercy Health System Audit & Compliance Committee Annual Charter Assessment Responsibilities of the MHS Audit and Compliance Committee The current policy Role of the Audit and Compliance Committee was approved on March 27, The purpose of the Committee is to assess, on behalf of the Board of Trustees, the independence of the company s internal and external audit, and compliance program. The Committee shall satisfy itself that open channels of communication exist among management, the internal and external auditors, and corporate compliance; and, shall inquire of management, the internal auditors and the external auditors concerning significant financial and compliance risks and assess the steps management has taken to address such risks. The Committee shall assess the activities of Internal Audit and Corporate Compliance departments. In addition, the Committee shall provide strategic oversight to the Corporate Compliance and Internal Audit Officers. Assessment of Committee Activities An assessment of the Committee s activities from the previous 12 months was performed. This assessment compares the responsibilities defined in the Charter to the actual activities of the Committee. Defined in the Charter Financial Reporting 1.01 Obtain a clear understanding of the financial reporting process within MHS and its component corporations Receive appropriate reports from auditors regarding their assessments of accounting and financial controls and financial reporting processes. Approval of the audit is not required Assess the accuracy of financial reporting by MHS and its component corporations. Internal Audit external auditors to review the results of the year end audit. external auditors to review the MHS portion of the consolidated CHE audit. external auditors to discuss the accuracy of the financial reports.

2 Defined in the Charter At least annually review the following: 2.01 Independence and reporting obligations of the internal 2.02 The organization of the internal audit group including its goals and objectives, the adequacy of its resources, and the productivity and competence of the audit staff The audit risk assessment process for the development of the Annual Internal Audit Plan The coordination of activities between the internal auditors and the external 2.05 Assess and review the results of the internal auditor s examination of internal controls as reported in audit report findings with management s response thereto Receive reports on the implementation of action plans and inquire of management on explanations for any deviations or deferments of those action plans 2.07 Receive updates on the status of the internal audit plan with explanations for any deviation from the original plan 2.08 Arrange for the presentation of the Annual Status Report to the Board Deloitte internal audit reports directly to the committee at each Deloitte internal audit presents quarterly to review the status of the audit plan. The Deloitte internal auditor reviewed this process at the September Periodic meetings were held between internal and external auditors to discuss coordination of audit activities. The committee reviewed audit reports by presented by Deloitte. Follow up on the implementation of management responses to audit reports was reviewed. Reports were given on the status of the internal audit plan. Deviations from the original plan were presented to and accepted by the Committee. The annual status report will be presented at the March , 15, September 15, 1 st quarter 15 May 6, March 17, May 6, November 16 March 2011 Page 2 of 5

3 Defined in the Charter 2.09 Assess the performance of the internal auditors External Audit Annual assessment of internal audit was performed by survey. Survey conducted in July- August Assure external audit accountability to the MHS Board of Trustees Approve all non-audit services in excess of $50,000 to be performed by the external 3.03 Obtain notification of all nonaudit services less than $50,000 to be performed by the external 3.04 Suggest deleting this requirement. External audit was reviewed at the April No non-audit services from the external auditors were performed in the past 12 months. No non-audit services from the external auditors were performed in the past 12 months. N/A N/A 3.05 Review the draft audit report resulting from the annual audit Review any audit adjustments in aggregate and the nature of the adjustments identified during the annual audit Review the application of accounting principles made in the annual audit report Review any alternative accounting treatments identified by the external 3.09 Review matters required to be communicated by the external auditors to the Committee Report the results of the external audit to the MHS Board of Trustees. The Committee entered into an executive session with the external The Committee Chair presented a summary of the external audit to the Board of Trustees. May meeting? Page 3 of 5

4 Defined in the Charter 3.11 Assess and, if necessary, take appropriate action to assure the continuing independence of the external Corporate Compliance 4.01 Review and approve the annual Internal Audit/ Compliance Risk Assessment and Plan Confirm that an appropriate compliance program is developed and implemented Receive update reports on the compliance plan 4.04 Report the status of the compliance program to the MHS Board of Trustees As necessary, provide oversight on corporate integrity agreements, settlement agreements or similar arrangements or administrative orders. Other 5.01 Review on an annual basis the MHS Code of Conduct and the program established by Management to monitor compliance with such Code Monitor legal matters, contingencies, claims or assessments and understand how such matters could have a significant impact on the MHS financial results. No action taken. Auditor independence was maintanined. The annual compliance plan was presented and approved by the Committee. Revision was also approved. The Committee has received and accepted reports on a regular basis. Status reports on compliance work plan have been presented and accepted by the Committee. Not done yet in. Compliance officer reported regularly on OIG settlement agreement. The MHS Code of Conduct was reviewed at the March The Committee was informed about investigations and corrective actions at each of the acute care hospitals. November 24, 2009 and March 17, 16, May 6, September 15, 16, March 17, 16, Page 4 of 5

5 Defined in the Charter 5.03 Update this policy annually and obtain Board of Trustee s approval of any revisions 5.04 Meet with external auditors and internal auditors without management s presence The policy was reviewed and updated at the November The Committee entered into an executive session at several meetings.. November 16, March 17, April 14, May 6, 5.05 The Committee will at least annually perform an assessment of its performance of its responsibilities under this policy and present this assessment to the MHS Board of Trustees This document serves as the Committee s assessment of its performance. November 16, Page 5 of 5