Fairness and Consistency Are Key to the Office of Program Integrity

Doing the right thing and exercising fairness and consistency are principles upon which the Office of Program Integrity, abbreviated as OPI, operate as an independent appraisal role vital to ADPH operations.

The office serves the State Health Officer by providing the following assurances:

  • Integrity of the department’s financial systems
  • Compliance with federal audit requirements
  • Compliance with applicable state laws and regulations.OPI also serves as consultant for the programs, services, and functions of the department.

Debra Thrash, who holds the designations of both C.P.A., Certified Public Accountant, and C.I.A., Certified Internal Auditor, has directed the office since April 1999. Reflecting on her career with ADPH, she said, "I thoroughly love what I do, and I have been blessed to use my accounting degree and to be in this department. Throughout the years, we have had the opportunity to help identify weaknesses and problems and to make recommendations to foster changes.”

The audits identified errors with the application of departmental procedures, manual processes prone to errors, and redundancies in data that would lead to discrepancies. Improvements in information technology have allowed system development by the Bureau of Information Technology to address findings and recommendations from OPI, such as the electronic day sheet, HEART, HEART-II, TimeTrac, and the electronic HIPAA Log.

Formerly, the department used a manual day sheet system for fee collection and reporting. Audits found there were problems with the legibility of the handwritten reports, and the E-Day Sheet system has not only helped address legibility, the system sends an automated report to Financial Services. HEART, HEART-II, and TimeTrac combine weekly leave usage and cost accounting. These systems have helped from an auditing standpoint by eliminating manual calculations and by reducing the need for employees to input redundant information in multiple locations, which reduces reporting errors. Finally, the electronic HIPAA Log was developed to track and monitor the timely completion of documents.

When Ms. Thrash joined ADPH 33 years ago, the office was then known as the Office of Internal Audit. The name was changed to the Office of Program Integrity in the mid-1990s to better reflect the breadth of services provided. During that time, OPI had financial/administrative auditing staff that is customary with an internal audit shop, but also had nursing staff who evaluated medical records for quality of care. While the nursing component is no longer part of OPI’s routine auditing procedures, the scope of services has continued to grow.

OPI continues to include general audit and review services in the areas of internal controls, revenue and receipts, expenditures, property controls, and personnel. The priority remains federal program audits. The federal program audits include an examination of cost accounting, WIC, family planning, maternal and child health, immunizations, case management services, and remote patient monitoring. OPI also performs audits within the state level bureaus and divisions as staffing and time permit.

Subrecipient monitoring

OPI has been conducting subrecipient monitoring reviews for decades, and recently OPI expanded efforts in this area. Subrecipients are agencies with which ADPH has partnered to perform services using grant funds. OPI is not “the” subrecipient monitoring program for the department. The program managers have the primary contact with subrecipients, and program managers are responsible for their respective contracts and agreements.

OPI does have a role to help ensure ADPH is prepared for external audit. Ms. Thrash said, “We as an agency have to make sure we’re in compliance, and OPI will expand our responsibilities to make sure the department is complying and will assist bureaus and divisions to make sure they’re monitoring subrecipients appropriately. When we accept federal money, strings are attached, and the biggest requirement is documentation.”

Subrecipient monitoring can include many different activities. The key is to document how the activity relates to the award, and that the purpose of the activity was to monitor the subrecipient. For example, a program manager who conducts a Webex meeting or call with a subrecipient and asks how things are going is generally inquiring about the project’s goals and asking about the progress towards achieving the goals.

“This is monitoring,” Ms. Thrash said. “Document the meeting as a monitoring activity. On the fiscal side, expenditures must be reasonable, necessary, allowable, and allocable. They must be supported, and within the budget. Monitoring fiscal activities requires more than sending invoices to Finance for payment.” Other documentation of subrecipient monitoring may include the receipt of quarterly reports and attendee registration sheets to verify trainings were held.

The current focus is on auditing COVID-19 expenditures and to ensure compliance with 2CFR (Code of Federal Regulations) 200 Uniform Guidance which addresses all three phases of the grant life cycle: pre-award, during the award, and award close-out. To facilitate, OPI staff will offer technical assistance and provide a report to identify deficiencies and areas for improvement. OPI will then help managers work through a corrective solution. Guidelines are being created to clarify the 2CFR 200 requirements.

Challenges of OPI

One of the challenges of OPI is correctly evaluating the differing fees charged by county health departments because each county’s fees for certain services vary based on local legislation or a local fee bill. Vital Statistics fees, on the other hand, are uniform statewide because they are based on state law. The audit of revenues and receipts would be much easier if all counties charged the same fees.

OPI, like other offices, also faces staffing challenges. Once staffed with auditors in each of the public health districts, OPI now has two auditors who conduct audits statewide. There seem to be two main issues preventing growth in staffing. First, there is not a specific “auditor” register; OPI selects auditors from the “accountant” employment register provided by the State Personnel Department. Ms. Thrash dispelled a common belief that there is little difference between accounting and auditing. She explained, “Accounting processes financial transactions and generates reports and auditing evaluates those reports and the processes used to prepare them. An accountant may deal with one area of accounting, for example, receivables or payables; but in auditing we tend to touch all of them. If we don’t understand a particular area, we have to dig for it, so we must be ‘jacks of all trades.’ Thankfully, there are resources and people we can turn to in the department.” Second, the registers have very few applicants. “It has been our experience that only about one-third to one-half of the applicants request an interview for an auditing position that requires travel.”

When asked if the department had ever experienced any serious issues that were identified through audits, Ms. Thrash acknowledged there had been a few instances where employees were embezzling or misappropriating funds. She explained, there is a recognized “fraud triangle” whose components are “a perceived, unshareable financial need, perceived opportunity to commit fraud, and rationalization of committing the fraud.” Back in the 1990s, after receiving a report from the area staff that something was wrong, OPI conducted an audit to substantiate the claim. After the investigation, management presented the information to the employee and the employee was given the opportunity to resign and make restitution. In another case, several years later, after the auditor arrived, the auditor noticed that the receipts and deposit amounts did not match. The auditor contacted Ms. Thrash and was told to make inquiries. When asked, curiously, the employee said, “I didn’t expect you back so soon.” This employee was also embezzling money, and this case was turned over to the local district attorney for prosecution.

When asked about the difference between how the two employees were treated, she said, “I would have turned the first one over to the local district attorney.” She went on to explain, “My training has taught me, supervisors are often willing to let employees suspected of corruption go on to other positions; to free themselves up; and to not be bothered by the situation, they pass them on. My belief is that we must deal with it when it is discovered. For the employees who may have that 'perceived, unshareable financial need,' I do have compassion. That’s what the Employee Assistance Program is for. Actions have consequences. And, not acting when action is required is detrimental to the rest of the staff and to the department. It sends the wrong message.”

Fortunately, instances like these are few and far between. Most often, audits are routine and involve ordinary test procedures and communications with local staff. Auditors engage with the nursing, social work, and other staff to review documents that support billing or other transactions. They also engage with administrative staff to monitor county imprest accounts used to pay utilities to verify they are reconciled. OPI evaluates internal controls and proposes segregation of duties.

OPI recognizes county health departments are short-staffed and tries to be as minimally invasive as possible when conducting their audits. In the past, audits took 3 to 4 weeks to complete on-site. Now, the on-site time has been reduced to about 1 to 2 weeks with the remainder of the work conducted remotely from the base. This change has cut down on some expenses for travel.

Meet the expert OPI staff

Heading the office is Ms. Thrash, who joined ADPH after earning a B.S. degree in accounting from Troy State University. An Andalusia native, she and her husband have been married for 34 years, and together have three children and will soon have six grandchildren. A Christian who loves serving the Lord, she enjoys music and her role as music director at Catoma Baptist Church.

In August, the couple relocated from their long-time home in a Montgomery subdivision to a river home 4 miles down a dirt road in Lowndesboro. She said, “There is peace there. I enjoy the simpler things--family and faith. The Lord has blessed me.” A 5-year breast cancer survivor, she is a strong advocate for mammograms. “People rallied around me when I was diagnosed. One lady gave me a treat bag on my surgery day, so I also give treat bags to others when they go in for breast cancer surgery. I believe that every breast cancer journey is different.”

In addition to her everyday responsibilities, since February 2021 she has served on the Supervisory Committee of the Alabama State Employees Credit Union which oversees the financial affairs and strength of the credit union. As a committee member, she works with internal and external auditors to ensure that all rules and regulations are followed.

Ms. Thrash is very proud of her employees. The OPI deputy director is Scott Burbank, C.P.A., who formerly worked as chief financial officer with the much smaller Alabama Tourism Department. “He is transitioning well into Public Health and the many different programs we administer.” OPI currently employs two full-time auditors, based in Coffee and Russell counties. The auditors are very detail oriented. Leslie Smith has been with the office since 2001. “She handles any task I assign her,” Ms. Thrash said with pride. Newly hired Katherine Grantham previously worked as the finance officer at the local Department of Human Resources office in Russell County. “She, too, is transitioning well into the auditing world. I am confident she will have a long future with Public Health.”

Two retired state employees provide audit support: Former WIC Nutrition Director Denise (Pope) Collins, R.D.N., and former audit director of the Department of Human Resources Steve Burden. Another retiree, Angie Garnett, brings life to the office, Ms. Thrash said. She formerly served as office manager for the Autauga County Health Department. “The Retired State Employee positions have been a blessing to our OPI team. Each position brings a unique skillset providing support to the office.” Rounding out the staff is talented Administrative Support Assistant Ashley Price who recently transferred from the Department of Conservation and Natural Resources to OPI. “We are fortunate to have Ashley onboard. I am encouraged she will do very well in OPI.”

When looking at the entire picture of OPI, Ms. Thrash wants to make sure the office is fair and consistent. “I don’t want to cite a county in one part of the state for something that doesn’t get mentioned in another. I’m in a unique position to be on both sides of the audit table. This is how I view this office. OPI audits are preparing bureaus, offices, and clinics to be audited by the external auditors. We recognize that OPI visits are not always popular, but it is far better for us to identify problems internally than to have an external auditor shine a spotlight on a deficiency. When we identify the issues first, it allows us to demonstrate that ADPH is being responsible and proactive with the resources we have been given.”

Office of Program Integrity Staff

Shown, from left, are OPI team members Steve Burden, Katherine Grantham, Angie Garnett, Leslie Smith, Ashley Price, Debra Thrash, Denise Collins and Scott Burbank.