A Performance Audit
An Audit Report on Health-related Programs at the Department of Licensing and Regulation
The Department of Licensing and Regulation (Department) has developed processes and related controls to administer and regulate its 13 health-related programs as required by statute, Texas Administrative Code (rules), and Department policies. However, those processes and controls were not sufficient to ensure appropriate monitoring of licensed facilities.
In addition, the Department should strengthen processes and controls to ensure that licensing and enforcement are performed adequately to meet the Department’s goal of protecting the health and safety of Texans.
The Department Should Strengthen Its License Application Review Process to Ensure That Eligibility Documentation Is Consistently Collected and Retained
The Department has developed a process for issuing both new and renewal licenses for its health-related programs to qualified applicants as required by statute and Texas Administrative Code (rules).
However, the Department should strengthen its quality control process by ensuring that documentation is retained showing applicants are eligible to receive Massage Therapy and Speech-Language Pathologists and Audiologists (SPA) licenses.
The Department’s Monitoring Framework Was Not Sufficiently Enforced to Help Ensure That Licensed Facilities Complied with Department Requirements
As part of its monitoring framework, the Department developed certain processes, tools, and controls to standardize the inspection process and oversee the quality of inspections. However, the Department did not sufficiently implement that framework to help ensure that all licensed facilities were properly monitored on a regular basis as required. Specifically:
- Field inspectors did not always complete a Proof of Inspection and a checklist as required by Department policy.
- Some program checklists identified specific requirements that if not met resulted in a referral to the Enforcement Division. However, other requirements of a similar type within the same checklist did not necessitate an enforcement referral.
- While the Department established certain processes to monitor the quality of inspections, it did not ensure that those processes were performed.
While Department management asserted that regional managers performed quarterly validation reviews to verify the accuracy of inspection results documented in VERSA, those reviews did not identify the significant data inaccuracies that auditors identified. In addition, the lack of application controls on selected key data fields and written procedures on how to document inspection outcomes in VERSA contributed to incomplete and inaccurate data.
The Department implemented sufficient controls and processes to help ensure that it adequately enforces regulatory activities in accordance with statute and the Texas Administrative Code (rules). However, the Department should strengthen its controls to help ensure that (1) it pursues the suspension or revocation of a license when administrative penalties are not paid and (2) each of the Department’s 13 health-related programs has a penalty assessment matrix and criminal conviction guidelines.
Auditors determined that VERSA lacked specific application controls to ensure that the data maintained was complete and accurate for the Department’s monitoring process.
The Department has established policies and procedures for its information systems; however, the Department does not consistently apply certain general controls.
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