Internal Audit
Contact Us:
208 Bull Street
Savannah, GA 31401
(912) 395-5844
Audit Reports
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- Summary of Reports
2024 Audit Reports
School Nurse Summary Report
School Nurse Summary Report
- Executive Summary
- Objectives, Scope, and Methodology
- Background
- Internal Control Questionnaire
- District Management’s Response
- STEM Academy at Bartlett
- Garrison K-8 School
- Gould Elementary School
- Hesse K-8 School
- Hodge Elementary School
- Islands High School
- Savannah High School
- White Bluff Elementary School
- Full Document
Executive Summary
The Internal Audit Department has completed Nurse Reviews at 8 schools.
School Name |
Findings Error Rate |
---|---|
STEM ACADEMY at BARLETT |
0% |
GARRISON K-8 SCHOOL |
3% |
GOULD ELEMENTARY SCHOOL |
15% |
HESSE K-8 SCHOOL |
2% |
HODGE ELEMENTARY SCHOOL |
11% |
ISLANDS HIGH SCHOOL |
31% |
SAVANNAH HIGH SCHOOL |
11% |
WHITE BLUFF ELEMENTARY SCHOOL |
0% |
|
|
Objectives, Scope, and Methodology
· The objectives of the reviews were to test internal controls performed by the School Nurse at designated schools, and to provide the principal with feedback on how to strengthen controls based on findings.
· In addition, this report will serve as a resource to the District’s Lead Nurse for developing uniform procedures within the District.
· The procedures included a review of written policies and procedures, school clinic observations, and sampling documentation for compliance by examining supporting documentation and electronic records.
Internal Audit conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that the audit be planned and performed to obtain sufficient, appropriate evidence to provide a reasonable basis for findings and conclusions based on the audit objectives. Internal Audit believes the evidence obtained provides a reasonable basis for the findings and conclusions based on the audit objectives.
Background
“School nursing, a specialized practice of public health nursing, protects and promotes student health, facilitates normal development, and advances academic success. School nurses, grounded in ethical and evidence-based practice, are the leaders that bridge health care and education, provide care coordination, advocate for quality student-centered care, and collaborate to design systems that allow individuals and communities to develop their full potentials.” As approved by the NASN Board of Directors June 2016.
Nurse Reviews are conducted each time a principal is assigned to a different school. Internal Audit may also schedule the reviews at schools when the leadership has not changed. The goal is to review each school at least once every three years. This assures principals and Central Office administrators that internal controls continue to work as designed for new and established principals.
Internal Control Questionnaire
Internal controls help establish accountability and provide feedback to managers on whether operations are working as expected. Testing of controls is not meant to identify individuals not following procedures, but rather a check to ensure that policies and procedures are being complied with. Because internal controls involve specific procedures for tasks, a system of internal controls should be a part of making the work smoother for all parties. Although some employees may feel that internal controls are restrictive, controls are tools to help ensure that organizational objectives are met.
When internal controls are not functioning as intended, there is an increase in the risk of not meeting organizational objectives. Resources may be wasted as a result.
Internal control failures often result in employees having to spend unnecessary time to correct a problem; they may result in violations of law or regulations that jeopardize State, Federal, or other funds. They may also undermine the District’s ability to serve its students.
Everyone in an organization has some responsibility for internal controls, but an organization’s leaders are ultimately responsible and must assume “ownership” of the internal controls for their area of responsibility.
Internal Audit has developed a list of questions to assess the internal control environment in a school. When there is a change in principal at a school, it is particularly important to assess whether the internal controls for key business processes function as they should, and whether the internal control environment – the attitude about internal controls – at the school site is as strong as it should be. This assessment will help the leadership at the school site determine whether changes are needed to effectively manage the business processes. The Internal Auditor and the principal at the beginning of each initial Business Process Review complete the Internal Control Questionnaire (ICQ) jointly.
District Management’s Response
The SCCPSS District Nursing Team strives to ensure all team members are performing at best practice levels. We appreciate the opportunity to review the effectiveness of internal controls through the internal audit process.
A written reminder to thoroughly complete the documentation was sent to all team members following the receipt of this report. Team members were also instructed to review documentation protocols with their unlicensed assistive personnel, and staffing partners were asked to notify substitute nurses that a medication count should be conducted both before and after shift assignments.
STEM Academy at Bartlett
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. All student medical forms reviewed followed District guidelines. Internal controls in this area appear to be functioning appropriately; therefore, we have no recommendations.
Garrison K-8 School
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· One out of the 15 students we reviewed had an incomplete Authorization to Give Medication at School Form.
The Authorization to Give Medication Administration at School Form is designed to document when and the dosage amount of the medication that was provided to the student. If any areas of the form are not followed, the form provides a legend key to make anecdotal notes as to the reason the instructions were not followed.
Recommendation:
· The student’s Authorization to Give Medication at School Form and Medication Administration Form need to be completed in their entirety to ensure compliance with State Law and provide direction to the school nurse to meet the student needs. All actions of the school nurse, as it relates to the administration of medication, should be documented on this form, and completed as defined.
Gould Elementary School
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Two out of the five students we reviewed had an incomplete Medication Administrative Form.
The Medication Administration Form is designed to document when and the dosage amount of the medication that was provided to the student. If any areas of the form are not followed, the form provides a legend key to make anecdotal notes as to the reason the instructions were not followed.
Recommendation:
· The student’s Medication Administration Form needs to be completed in their entirety to ensure compliance with State Law and provide directions to the school nurse to meet the student needs. All actions of the school nurse, as it relates to the administration of medication, should be documented on this form, and completed as defined.
Hesse K-8 School
NURSES
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· One out of the 15 students we reviewed had an incorrect medicine count.
The Medication Administration Form is designed to document when and the dosage amount of the medication that was provided to the student. Daily logs are in place to ensure that the medicine count is documented accurately to ensure medication is accounted for.
Recommendation:
· All actions of the school nurse, as it relates to the administration of medication, should be documented, and completed as defined. The accounting for medication should be completed daily to ensure medication count is accurate.
Hodge Elementary School
NURSES
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· One out of the three students we reviewed had an incomplete Medication Administrative Form.
The Medication Administration Form is designed to document when and the dosage amount of the medication that was provided to the student. If any areas of the form are not followed, the form provides a legend key to make anecdotal notes as to the reason the instructions were not followed.
Recommendation:
· The student’s Medication Administration Form needs to be completed in their entirety to ensure compliance with State Law and provide direction to the school.
nurse to meet the student needs. All actions of the school nurse, as it relates to the administration of medication, should be documented on this form, and completed as defined.
Islands High School
NURSES
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Five of seven student’s Medication Administration Forms were not documented daily to identify if medication was administered as required.
The Medication Administration Form is designed to account for timing and action of the student receiving the medication as directed on the Authorization to Give Medication. The form also accounts for the medicine count as the medicine is disbursed.
Recommendation:
· The student’s Medication Administration Form needs to be completed in its entirety to ensure compliance with State Law and provide direction to the school nurse to meet the student needs. All actions of the school nurse, as it relates to the administration of medication, should be documented on this form, and completed as defined.
Savannah High School
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· One out of the three students we reviewed had an incomplete Medication Administrative Daily Form.
The Medication Administration Form is designed to document when and the dosage amount of the medication that was provided to the student. If any areas of the form are not followed, the form provides a legend key to make anecdotal notes as to the reason the instructions were not followed.
Recommendation:
· The student’s Medication Administration Form needs to be completed in its entirety to ensure compliance with State Law and provide direction to the school nurse to meet the student needs. All actions of the school nurse, as it relates to the administration of medication, should be documented on this form, and completed as defined.
White Bluff Elementary School
NURSES
Internal Audit conducted walkthrough observations and reviewed documentation for four students to ensure compliance with Board Policy and Regulations. Internal Audit found all student medical forms reviewed followed District guidelines. Internal controls in this area appear to be functioning appropriately; therefore, we have no recommendations.
Full Document
Summary of School Nutrition Inventory Reviews
Summary of School Nutrition Inventory Reviews
- Executive Summary
- Objectives, Scope and Methodology
- Background
- Internal Control Questionnaire
- School Nutrition Program
- District Management’s Response
- STEM Academy at Bartlett
- Garrison K-8 School
- Godley Station K-8 School
- Gould Elementary School
- Hesse K-8 School
- Hodge Elementary School
- Islands High School
- JG Smith Elementary School
- Marshpoint Elementary School
- New Hampstead K-8 School
- Savannah High School
- West Chatham Elementary School
- West Chatham Middle School
- White Bluff Elementary School
- Full Document
Executive Summary
The Internal Audit Department has completed School Nutrition Inventory Reviews at 14 schools.
School Name |
Findings Error Rate |
---|---|
STEM ACADEMY AT BARTLETT |
6% |
GARRISON K-8 SCHOOL |
17% |
GODLEY STATION |
0% |
GOULD ELEMENTARY SCHOOL |
27% |
HESSE K-8 SCHOOL |
7% |
HODGE ELEMENTARY SCHOOL |
20% |
ISLANDS HIGH SCHOOL |
17% |
JG SMITH ELEMENTARY |
3% |
MARSHPOINT ELEMENTARY SCHOOL |
6% |
NEW HAMPSTEAD K8 |
0% |
SAVANNAH HIGH SCHOOL |
7% |
WEST CHATHAM ELEMENTARY SCHOOL |
6% |
WEST CHATHAM MIDDLE SCHOOL |
0% |
WHITE BLUFF ELEMENTARY SCHOOL |
7% |
Objectives, Scope and Methodology
· The objectives of the reviews were to test food inventory controls performed by the School Nutrition personnel at designated schools.
· In addition, this report will serve as a resource to the Senior Director of School Nutrition for developing uniform inventory procedures.
Internal Audit conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that the audit be planned and performed to obtain sufficient, appropriate evidence to provide reasonable basis for findings and conclusions based on the audit objectives. Internal Audit believes the evidence obtained provides a reasonable basis for the findings and conclusions based on the audit objectives.
Background
School Nutrition Reviews are conducted each time a principal is assigned to a different school. Internal Audit may also schedule the reviews at schools when the leadership has not changed. The goal is to review each school at least once every three years. This assures principals and Central Office administrators that internal controls continue to work as designed for new and established principals.
Internal Control Questionnaire
Internal controls help establish accountability and provide feedback to management on whether operations are working as expected. Controls are not meant to identify individuals not following procedures, but rather a check to ensure that policies and procedures are being complied with. Because internal controls involve specific procedures for tasks, a system of internal controls should be part of making the work smoother for all parties. Although some employees may feel that internal controls are restrictive, controls are tools to help ensure that organizational objectives are met. When internal controls are not functioning as intended, there is an increase in the risk of not meeting organizational objectives. Resources may be wasted as a result.
Internal control failures often result in employees having to spend unnecessary time in order to correct a problem and they may also result in violations of law or regulations that jeopardize State, Federal, or other funds. These failures may also undermine the District’s ability to serve its students.
Everyone in an organization has some responsibility for internal controls, but an organization’s leaders are ultimately responsible and must assume “ownership” of the internal controls for their area of responsibility.
Internal Audit has developed a list of questions to assess the internal control environment in a school. When there is a change in principal at a school, it is particularly important to assess whether the internal controls for key business processes function as they should, and whether the internal control environment – the attitude about internal controls – at the school site is as strong as it should be. This assessment will help the leadership at the school site determine whether changes are needed in order to effectively manage the business processes. The Internal Auditor and the principal complete the Internal Control Questionnaire (ICQ) jointly at the beginning of each initial Business Process Review.
School Nutrition Program
The food service program, as an extension of the educational programs of the schools, is operated under the federally funded National School Lunch Act and Child Nutrition Act. The School Nutrition Program receives federal reimbursement for eligible meals served to all students. Other revenue is generated from meals sold to paying and reduced students, a la carte sales, and adult meals and catering. The federal laws regulating the food service programs are administered by the United States Department of Agriculture through the regional office and implemented within the State by the Georgia Department of Education. The program's objective is to improve the health of students by providing a variety of palatable, high-quality, safe, nutritious foods that students will enjoy eating at a price affordable to them. The menus are planned by a Registered Dietitian and Chef.
District Management’s Response
District Management’s Response
• SNP Nutrition Summary Report SY 22.23 reviewed with Coordinators– Friday, Feb 16, 2024
• Inventory: Product Receiving, Storing, Usage and Recording SOPs designed. Introduction and formal training for all School Managers scheduled for SNP Monthly Managers Meeting, Monday, Feb 19, 2024. Hard copy to be distributed during meeting.
• Electronic Copy of Inventory SOP sent to all Site Managers.
• Inventory Variance Tracking Spreadsheet [Dec-Jan 23] prepared by Coordinator for all sites. Results shared with Coordinators & Executive Director.
• Inventory Variance Tracking Tool will be prepared monthly. Variances [+/-] will be addressed immediately as to cause and corrected.
• Note: The responsibility of Inventory maintenance rests on the Manager with support during the physical inventory of the Lead. The following causes for Inventory Variances identified on SNP Nutrition Summary Report SY 22.23 have been identified as follows: [corrections additional to group retraining are parenthesized]
o Islands HS: [Manager out, Lead acting as Interim Manager]
o Hodge ES: [Multi-Site, Inventory at both sites, consideration to move Manager to smaller site]
o Savannah High: [Has been out 1-2x/wk. during the month. Site lacked consistent leadership]
o Marshpoint ES: [Untrained Manager. Scheduled for one-on-one training]
o Bartlett MS: [One-on-one training scheduled. Unbalanced delegation of responsibilities]
o Hesse K8: [Lead out all month]
o White Bluff ES: [Lead position vacant]
o JG Smith ES: [one-on-one retraining scheduled]
o Gould: [one-on-one training scheduled]
o West Chatham ES: [– one-on-one training scheduled]
STEM Academy at Bartlett
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Two out of 30 food inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food inventory at point of receipt is vital in ensuring inventory items are accurate and reduces the risk of theft.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted timely to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
Garrison K-8 School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Five of the 30 food inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted weekly and/or monthly to ensure food inventory is accurate to reduce food costs and to prevent potential theft.
Godley Station K-8 School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found no weakness in their inventory controls. All items were accounted for on the day of our review.
Internal controls in this area appear to be functioning appropriately; therefore, we have no recommendations.
Gould Elementary School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Eight out of 30 food inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted weekly and/or monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
Hesse K-8 School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Two out of 30 food inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted monthly and/or weekly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
Hodge Elementary School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
- Six out of 30 food inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
- A physical inventory of all food and paper product inventory items should be conducted weekly and/or monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
Islands High School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Five out of 30 food inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
JG Smith Elementary School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· One out of 30 food product inventory items reviewed did not match the quantity listed on the Inventory of Hand report
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
Marshpoint Elementary School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Two out of 30 food product inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
New Hampstead K-8 School
Savannah High School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Two out of 30 food inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
West Chatham Elementary School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Two out of 30 food product inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
West Chatham Middle School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Two out of 30 food product inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.
White Bluff Elementary School
SCHOOL NUTRITION PROGRAM
Internal Audit conducted walkthrough observations and reviewed documentation for compliance with Board Policy and Regulations. Internal Audit found the following:
· Two out of 30 food inventory items reviewed did not match the quantity listed on the Inventory of Hand report.
Accounting for food purchased by the District is essential in ensuring meals are served with the accurate ingredients to meet Federal Law as well as preventing theft of District funds.
Recommendation:
· A physical inventory of all food and paper product inventory items should be conducted weekly/monthly to ensure food ordering is accurate to reduce food costs and to prevent potential theft.