INTERNAL CONTROLS                                                                                                              34-02-002

INTERNAL CONTROLS REVIEW COMMITTEE

POLICY STATEMENT.

The Division of Veterans Healthcare Services requires that each of the New Jersey Veterans Memorial Homes (VMH) establish manuals of policies and procedures for providing services.  Procedures shall permit the organization of committees, as needed, to ensure and to set into operation the standards set forth for licensure of Long Term Care Facilities, in accordance with the regulatory codes set forth by the New Jersey Department of Health and Senior Services, the U.S. Department of Veterans Affairs, and the New Jersey Department of Military and Veterans Affairs.

PURPOSE.

This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial Homes implements an Internal Controls Program designed to maintain checks and balances of federal monies, review and audit areas of vulnerability, and direct change by developing controls to improve accountability and productivity.

PROCEDURE.

A:  New Jersey Veterans Memorial Homes shall establish an Internal Controls Coordinator, given the authority and charged with the responsibility for overseeing the Internal Controls Program within the facility.

1. The Internal Controls Coordinator shall function as an advisor to the Chief Executive Officer (CEO), and shall serve as the organizational line of communication between all the Departments and the CEO with respect to implementing the Internal Controls Program, and for assuring compliance with statutory requirements. 

a. The Departments shall be divided into three components, Clinical, Support and Business.

i. Each component shall be led by the respective Administrator who will coordinate the Assessment Process for his/her assigned department(s), and complete the “Control Self-Assessment” report as required.

ii. The Internal Controls Coordinator will combine the three reports into a single report and forward the single report to the DVHS and the Department’s Ethic’s Officer.

2. The Internal Controls Coordinator shall serve as the authority for overseeing all aspects of the Internal Controls Program to include the formulation, development, review and revision of procedures guiding Internal Controls Program implementation.

3. The Internal Controls Coordinator will complete the Internal Controls Assessment pursuant to the Department of Treasury’s official circular letter entitled “Annual Internal Control Reporting”

03-08-OMB, effective 01/02/03.  The Department of Treasury has developed an Internal Control Assessment questionnaire that incorporates the methodology contained in the report entitled Internal Control – Integrated Framework, published by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).  All executive branch agencies must use this questionnaire when performing their annual Internal Controls Assessment, unless specifically exempted by OMB.

Revised: January 2007