AOP Template

MONTEFIORE MEDICAL CENTERThe University Hospital 111 East 210th Street [Insert name]of the of the Albert Einstein Bronx, New York 10467 [Insert title]College of Medicine Tel.: (718) 920-6163 Department of Audit Services

Fax.: (718) 231-2724E-mail:

To: [Insert auditee/client]

From: [Insert auditor(s) names]

Date: [Insert date]

Subject: Audit Orientation Package

I (We) [change as appropriate] have attached an Audit Orientation Package for yourconvenience. This Audit Orientation Package has been assembled in order tofamiliarize the auditee/client with the audit processes and expectations during thevarious phases of the audit. In addition, this package will answer some of the morecommonly asked questions.

The Table of Contents at the front of this binder has been incorporated to assist you inlocating specific information about our department and the audit process.

Please note that the Audit Orientation Package will include the assigned auditor’sbiography (Tab D) and the scope and objectives of the review for the [change as

appropriate] (Tab G). In addition, the package includes a Sample Audit Report (Tab J)to help to familiarize the auditee/client with our audit report process. The package alsoincludes an Audit Effectiveness Questionnaire (Tab K), which asks the auditee/client torate the quality of the audit service provided by the audit team. Please complete thequestionnaire within a week after the completion of the audit and send the completedquestionnaire to Eugene Porter, Vice President of Audit Services.

Please call me (us) [change as appropriate] at 920-XXXX [insert phone number], contactme (us) [change as appropriate] by GroupWise, or e-mail me (us) [change asappropriate] at [email protected] [insert email address] if you have any questions orconcerns.

I (We) [change as appropriate] hope this package will assist you as you familiarizeyourself with the various activities of the Department of Audit Services. I (We) [changeas appropriate] look forward to working with you.

Audit ServicesAudit ServicesAudit Orientation Package

MontefioreMontefioreMedical CenterMedical Center

Vision:Vision:

Our vision is to use skilled auditors andstate-of-the art technology to provide theMontefiore community with accurate, highquality and objective audits, reviews andmanagement consulting services.

Montefiore Medical Center

The Department of Audit Services (DAS)

Audit Orientation Package

Table of Contents

The Charter of the Department of Audit Services -------------------------------- Tab A

Audit Area Identified--------------------------------------------------------------------- Tab B

DAS Organizational Chart ------------------------------------------------------------- Tab C

Auditor’s Biography---------------------------------------------------------------------- Tab D

The Audit Process ----------------------------------------------------------------------- Tab E

MMC Audit Recommendation Follow-up Policy & Procedure ----------------- Tab F

Scope and Objectives of the Review------------------------------------------------ Tab G

Audit Process Prerequisites ----------------------------------------------------------- Tab H

Audit Report Distribution Pyramid---------------------------------------------------- Tab I

Template of a Sample Audit Report ------------------------------------------------- Tab J

Audit Effectiveness Questionnaire --------------------------------------------------- Tab K

Tab A

Montefiore Medical Center

The Charter of the Department of Audit Services

Overview:

The Department of Audit Services (DAS) has been established as an independentfunction to examine, evaluate and report on the business, clinical, financial,compliance/regulatory and administrative operations of Montefiore Medical Center(MMC) and its affiliates to the Audit Committee of the Board of Trustees and as a serviceto management and administration. It is a managerial control which functions bymeasuring and evaluating the effectiveness of business processes and other controls todetermine whether:

Management information is reliable, MMC policies and procedures are followed, Established federal and state government standards are met and MMC assets and resources are safeguarded and used appropriately.

Objective and Scope:

The objective of DAS is to assist all associates of MMC in the effective discharge of theirresponsibilities by furnishing them with analyses, appraisals, recommendations andpertinent comments concerning the activities reviewed. This involves going beyond theaccounting and financial records to obtain a full understanding of the operations underreview. The attainment of this overall objective may involve such activities as:

Evaluating the efficiency and effectiveness of business and clinical processes. Reviewing and appraising the soundness, adequacy and application of

accounting, financial and other operating controls and promoting effectivecontrols at reasonable cost.

Evaluating the level of compliance with federal and state laws and governmentregulations, as established by, among other things, federal and state programsand agencies, such as Medicare, Medicaid, JCAHO, DOH, OSHA and DEA.

Utilizes CAATs (Computer Assisted Audit Tools) and other computerizeddatabase management tools to analyze and review trends, unusual patterns andunique activities and transactions.

Evaluating the level of compliance with MMC policies and departmentalprocedures and with the Montefiore Medical Center Code of Conduct.

Ascertaining the extent to which MMC assets are accounted for and safeguardedfrom losses of all kinds.

Ascertaining the reliability of management data developed within MMC.


Objective and Scope - Continued:

Appraising the quality of performance in carrying out assigned responsibilities.(Does not include appraising the quality of teaching, research or patient care).

Evaluating the effectiveness, efficiency and economy with which resources areemployed.

Recommending operating enhancements.

Responsibility and Authority:

The responsibilities of DAS are the following: To inform and advise management and to discharge this responsibility in a

manner that is consistent with the MMC Code of Conduct, the standards of theInstitute of Internal Auditors and applicable health care industry regulations.

To coordinate internal audit activities with others so as to best achieve the auditobjectives and the objectives of MMC.

To assist, when necessary, the Office of Corporate Compliance in internalinvestigations of alleged violations of the MMC Code of Conduct.

To submit annual audit plans to the President of MMC and the Audit Committeeof the Board of Trustees for their review and approval.

To meet with and report to the Audit Committee of the Board of Trustees at leastfour times per year on whether:1. Appropriate action has been taken on significant audit findings,2. Audit activities have been directed toward the highest exposures to risk and

toward increasing effectiveness, efficiency and economy of operations,3. Internal audit plans are adequate and4. There is any unwarranted restriction on the staffing and authority of DAS or

on access by internal auditors to all MMC activities, records, property andpersonnel.

DAS is provided with the authority for full access to all of the Montefiore MedicalCenter’s records, properties and personnel relevant to the subject under review. DAS isfree to review and appraise policies, plans, procedures and records.

In performing its functions, DAS has neither direct responsibility for, nor authority over,any of the activities that are reviewed. Therefore, the internal audit review and appraisaldoes not in any way relieve other persons in MMC of the responsibilities assigned tothem.


Independence:

The Vice President, Audit Services, reports to the President of Montefiore MedicalCenter, with direct access to the Audit Committee of the Board of Trustees. In order tomaintain objectivity, DAS will not undertake to develop and install procedures, recordsnor engage in any other activity which it would normally review and appraise, and whichcould reasonably be construed to compromise its independence. However, objectivityneed not be adversely affected by DAS’ determination and recommendation of thestandards of control to be applied in the development of systems and procedures underreview.

Adopted by the Audit CommitteeOf the Board of Trustees

Of the Montefiore Medical CenterOn the 22nd day of October 1998.

Tab BMontefiore Medical Center

Department of Audit Services (DAS)

Audit Area Identified

The Department of Audit Services reviews operational, clinical and financial areas ofMontefiore Medical Center during the audit year. The current audit year runs fromJanuary 200X through December 200X. Your department has been identified as anarea that the Department of Audit Services should review during the current-audit year.This decision was based on our risk matrix analysis.

The risk matrix analysis selects higher risk audit areas for review by determining thedepartment or activity that have potentially higher risk. Criteria for a potential high riskarea include the following high risk factors:

1. Special Board of Trustee requests,2. Regulatory agency driven (potential high risk in an area because of the high

emphasis for review of this area by a regulatory agency government and/orhealth care organization),

3. Changes in MMC’s profile (high risk based on recent rapid growth/declinerate in that segment),

4. Input from external sources (e.g., identified higher risk in area based on athird party review. E.g., an issue identified during the Ernst and Young year-end audit, a Consulting review or a JCAHO review),

5. Critical issues (e.g., potential for high risk because of the significance thisarea has as a revenue source to Montefiore’s business) and

6. Formal or informal input from internal sources (Informed of potential forhigher risk by Risk Management, Office of Corporate Compliance, or a priorAudit Services audit report).

Executive management and the Board of Trustees then reviewed the current auditschedule. The Audit Committee of the Board of Trustees approved this audit schedulefor the current year.

Your department was selected because it met one of the six criteria noted above.

Tab C

Department of Audit Services

Eugene PorterVice President

Vernon BenjaminDirector

Betty AlbaCAATs Manager

Karen SieverdingManager

Carmelito AndalSenior

Dong WenManager

Tab DAuditor’s Biography

Betty Alba

Betty Alba is a Computerized Analytical Audit Techniques (CAATs) Manager, whichsupports the Department of Audit Services (DAS). She has been with Montefiore MedicalCenter since 1993. She has performed operational, clinical, forensic and special requestreviews throughout different disciplines of the medical center. As the CAATs Manager,Betty utilizes the automated resources to assist in the audit process as well as with thedepartment’s risk assessment in the identification of audit candidates.

She has extensive knowledge in Health Care related activities as well as on the variouscomputer systems and applications supporting the Medical Center. She has knowledgeof Current Procedural Terminology (CPT) coding, International Classification of DiseasesClinical Modification, 9th Edition (ICD-9-CM) coding and medical terminology. Prior tojoining MMC, she used to be a Commission Consultant at Prudential Bache Securities.

Betty holds a Bachelor of Science in Accounting with a minor in Computer Science fromHerbert H. Lehman College. Betty has taken additional courses in Current ProceduralTerminology (CPT), International Classification of Diseases Clinical Modification, 9th

Edition (ICD.9.CM), medical terminology and other Health Care related courses,Structure Query Language (SQL), Audit Command Language (ACL) and other computersystems training.

Betty Alba can be contacted at (718) 920- 4460, through GroupWise e-mail or throughthe Internet e-mail, at [email protected].

A business card has been attached to this page for your convenience.


Vernon Benjamin

Vernon H. Benjamin is the Director of Audit Services for Montefiore Medical CenterDepartment of Audit Services. Vern has been with the Department of Audit Services forthe past six years. Vern has over 25 years of experience in supervising and conductingfinancial, operational and integrated audits for various industries.

Over the last several years, Vern has attended numerous computer training classes inorder to advance his computer skills. Vern is the department’s computer networkadministrator for its state-of-the-art computer LAN network. He has extensiveknowledge of the Microsoft NT operating system and has been instrumental in movingthe department to a paperless audit environment through the software program, LotusNotes.

Vern holds a Bachelor of Science degree in Accounting from Syracuse University.

Vern Benjamin can be reached at (718) 920- 2806, through GroupWise e-mail orthrough Internet e-mail at [email protected].



Carmelito “Sonny” Andal

Sonny Andal is a Senior Auditor in the Department of Audit Services. Sonny is new tothe department and has been with MMC since May 2008. Sonny has ten plus years ofaudit experience from various industries which include financial services,telecommunications and retail.

During that time he has gained extensive experience in evaluating and facilitatinginternal controls and accounting processes and procedures. Sonny’s ability to look atcontrol weaknesses in a process has benefited the companies he served through costsavings, recovery of assets and prosecution of criminals.

Carmelito holds a BBA Degree in Accounting from Pace University.

Carmelito Andal can be reached at (718) 920- 2804, through GroupWise e-mail orthrough Internet e-mail at [email protected].



Dong Wen

Dong Wen is a manager in the Department of Audit Services. Her bi-country workexperience includes financial planning, financial statements preparation, forensicinvestigation, as well as budget analysis.

In her prior position, Dong combined her knowledge of Accounting and Economics toanalyze budget and research results to position her company in a competitive role in themarket place. Her analysis and recommendations on strategies were presented to theBoard of Trustees.

Dong interned at the New York County District Attorney’s Office, where she gotextensive knowledge in forensic accounting.

Dong holds a Master of Art in Economics from New York University and a Master ofScience in Accounting from Pace University.

Dong Wen can be contacted by telephone at (718) 920-7356 or via GroupWise e-mail [email protected].


Tab D

Auditor’s Biography

Karen Sieverding

Karen Sieverding is a manager for the Department of Audit Services. She has workedat Montefiore Medical Center since 1997. During her tenure she has been involved inclinical, operational and special request reviews of various organizational functions.

Karen Sieverding is a registered nurse. Her professional experience includesadministrative responsibility for corporate-wide discharge planning, risk management,quality improvement and medical staff activities as well as the management of a freestanding Diagnostic and Treatment Center.

Karen holds a Bachelor of Science in Nursing from the State University of New York anda Masters of Science in Nursing from Pace University.

Karen Sieverding can be contacted by telephone at (718) 920-2807, through MMCGroupWise e-mail or through Internet e-mail at [email protected].


Tab EMontefiore Medical Center


The Audit Process

The successful audits are those in which the management and staff of the area auditedstay involved with the audit process and are aware of the phases that are common tomost audits. These phases include the following:

Selection – The selection of activities to audit is accomplished with a view tooptimize audit coverage addressing high-risk subjects and areas of managementconcern. Attempts are made to recognize and avoid duplication of effort byexternal auditors and consultants. In addition, the Office of CorporateCompliance may request DAS, when necessary, to investigate certain allegedviolations of the MMC Code of Conduct.

Preliminary Review and Planning – The auditor first gathers information aboutthe activity or process to be audited through corporate procedure manuals,reviews of relevant files and records, and reviews of current state and federalgovernment regulations and JCAHO standards, networking with other auditdepartments and utilization of the Internet. We also survey executivemanagement, before we identify the fieldwork objectives.

Notification – The management of the area to be audited and the Vice Presidentwith oversight receive an engagement letter which clearly summarizes the scopeand objectives of the audit, the auditor(s) assigned to the project and signals thestarting of the fieldwork phase of the audit. However, reviews conducted by DASbut which the Office of Corporate Compliance requests are conducted inconfidence. In such cases, prior notification, such as an engagement letter,would not be given before commencement of the audit.

Entrance Conference – This is a meeting held with the auditor andmanagement for introductions, discussion and clarification of issues.Discussions may involve such topics as the time period for the fieldwork, workingspace for the auditor(s) and other issues that the unit staff and/or auditor(s) needto address. Areas that management has identified as high-risk exposure orissues that have received management concerns are also discussed at this time.Again, reviews that have been requested by the Office of Corporate Complianceare conducted in confidence and an entrance conference would not be held inthese cases.

The Audit Process - Continued

Fieldwork – At this phase, the auditor concentrates on identifying elements ofinternal control and processes, gathering information and reviewing and testingtransactions. Procedures, such as the review of the unit files and records,medical records and informal discussions and interviews with unit staff are theprimary sources of information for the auditor. Therefore, it is important for theauditor to obtain easy access to unit files and records, staff and documentationthat may be obtained at other departments or locations, such as medical records.The auditor will keep management abreast of issues as they arise to provide aclear, precise and timely understanding of the issues noted (See Tab G). TheDAS philosophy is to minimize operational disruption throughout the auditprocess while meeting DAS productivity and time deadlines for the assignment.

Audit Point Sheet(s) – During fieldwork, all opportunities for improvement thathave been identified by the auditor will be brought to the attention ofmanagement within 24 hours of discovery. Audit Point Sheets are reviewed withappropriate management to ensure accuracy and validity. Corrective plans ofaction will be written by management and will include the expected dates ofresolution within 48 hours. The reviewed Audit Point Sheet(s) becomes the basisof the draft audit report.

Draft Audit Report – This draft generally reflects the reporting areas ofopportunities for improvement and planned enhancements and corrective actionsafter the auditor and the audit management collectively evaluate the significanceof each finding. The draft report becomes the document that is presented tomanagement for discussion towards the end of the audit.

Final Audit Report – This is the final product of the audit where observedopportunities for enhancements and comments are presented together withmanagement’s plan for enhancements and actions. The audit report distributionis limited to the individuals noted in the audit report distribution pyramid (SeeTab I). Information in the audit report is maintained in highest confidence.

Follow-Up Audit – The audit process ends with the issuance of the final auditreport. Issues raised during the audit are incorporated in the Follow-Up Notices,which are sent to medical center administration and management monthly and tothe Board of Trustees at least four times a year for review. After all issues havebeen resolved, the next phase is the Follow-Up Audit. During the Follow-UpAudit, issues raised during the original audit process are reviewed to ensureproper and timely resolution of the issues has resulted.

Tab F

MONTEFIORE MEDICAL CENTERThe University HospitalFor the Albert EinsteinCollege of Medicine

Henry and Lucy Moses DivisionJack D. Weiler Division

ADMINISTRATIVE POLICY AND PROCEDURE

SUBJECT: Audit Recommendation(s) Follow-upPolicy

NUMBER: JF01.1OWNER: Department of Audit Services

EFFECTIVE REVISED SUPERSEDES:DATE: 7/31/92 DATE: 9/30/2006

REFERENCE: N/A

Purpose: It is Montefiore Medical Center (“MMC”) policy that Managementrespond to audit recommendations on an adequate and timely basis.

Scope: 1) This policy applies to all MMC departments, divisions, units and linesof business.

2) This policy applies to audits conducted by the Internal AuditDepartment, MMC’s independent (outside) auditors, and auditsconducted by any government or regulatory agency.

3) This policy does not pertain to occupational safety and environmentalprotection inspections, surveys or site visits for hospital residencyprogram accreditation; nor to medical specific surveys conducted eitheron a scheduled or periodic basis or surveys or inspections arising froma medical or patient incident.

1



Contact the Internal Audit if uncertain as to whether an audit, inspection,accreditation review, survey or site visit pertains to this policy.

Definitions: For the purpose of this policy the term “Audit” means any appraisalof MMC operations and/or controls conducted to determine whether:

1. risks are being identified and reduced,2. acceptable policies/procedures exist and are being followed,3. established standards are being met,4. resources are being used economically, and/or5. objectives are being achieved.

The above definition includes investigations or reviews arising fromspecific incidents or alleged incidents of a non medical nature.

Application: 1) Associates (employees) are to promptly notify the pertinent VicePresident, Site Director or Departmental Administrator (who willinform the Chairperson) of any such scheduled audits (or audits inprocess).

2) Vice Presidents, Site Directors and Departmental Chairpersonsmust promptly advise the Director of Internal Audit of any auditsscheduled (or already taking place when this policy is issued) intheir area(s) of responsibility.

3) A copy of a completed audit report must be forwarded to theInternal Audit Department within one week of receipt in anaudited area.

4) Internal Audit will review audit report findings, conclusions andrecommendations.

Depending upon the nature of the report findings Internal Auditpersonnel may meet with MMC associates to discuss audit findings,responses and time frames for implementing corrective actions.

2



5) Internal Audit will follow-up on a scheduled basis to determine whether auditresponses/actions are still outstanding and required by affecteddepartments(s).

The status of audit corrective measures requiring implementationwill be reported to senior management on a regular basis.

Regulatory Reference: N/A

Responsibility: 1) Vice Presidents, Site Directors and Departmental Chairpersonsare responsible for execution of and compliance with thispolicy within their organization.

2) The Internal Audit Department is responsible for ensuring thatthis policy is kept up to date.

3

Tab GMontefiore Medical Center


Scope and Objectives of the Review

EXAMPLE: [change as appropriate]Audit of Health Services Receivables

The Department of Audit Services will be conducting a review of HealthServices Receivables inpatient collections. The objectives of our audit are toreview whether the medical center is adequately monitoring the level of baddebts, denials and write-offs and to determine whether the medical center isappropriately utilizing collection agencies to maximize the rate of collection.Our scope will be limited to inpatient collections.

Tab HMontefiore Medical Center

Department of Audit Services (DAS)Audit Process Prerequisites

Auditor’s Commitment to You

Confidentiality of theinformation/material source

Business card of DAS auditor- To facilitate better

communication betweenauditor and auditee/client

Knowledge of the duration offield work and issuance ofdraft report

No surprises- A key auditee/client,

identified bymanagement asthe”point person” will beaware of all issues on atimely basis and will helpto validate and bringresolution to issuesraised.

- Constant and immediateareas for improvementwith their suggestedrecommendation will flowbetween auditor andauditee

Full credit will be given tomanagement for opportunities forimprovement that they haveidentified

What Is Required from Auditee/Client

Identify to auditor areas ofconcern

Identify or reveal to auditorany conditions which couldimpact or change the scope ofthe audit, such as thefollowing:

- New and/or plannedcomputerized or manualsystems,

- Recent managementconsultant reports,

- Recent reviews byfederal or stateregulatory agencies, and

- Staff changes andturnover that wouldimpact the audited area.

Identify to auditor keydepartment personnel orpersonnel outside thedepartment which couldsignificantly impact thedepartment and help smooththe audit process

Identify to auditor theavailability and timeliness ofall needed documentation

- Please note that DAShas full authority andjurisdiction to access allof MMC’s records,properties and personnelrelevant to the subjectunder review

Department of Audit ServicesDepartment of Audit ServicesAudit Report Distribution PyramidAudit Report Distribution Pyramid

Directors, Administrators,Practice Managers, Chiefs ofService, Department Heads

S. Safyer,M.D.

BOT*

Vice Presidents,Chairperson(s)

ExecutiveLevel

* BOT = Members

of the AuditCommittee of theBoard of Trustees

Tab I

DAS takes a bottom-up approach to all audit reports. Only afterinput and review from the immediate level involved will the report betaken to the next level.

Tab J

Audit Report Template

Medical Center

[AUDIT AREA UNDER REVIEW]

[AUDIT DATE]

Prepared By:[Auditor’s Name]

Audit Report #_ -_

A – Ancillary Services F – Faculty PracticeB – Children’s Hospital G – Medical GroupC – Clinical H – Home Health AgencyD – Diagnostic Services M – Managed CareE – Corporate X – Implementation Follow-up

Purpose

[PURPOSE OF AUDIT]

Scope

(SCOPE OF AUDIT)]

Background

[BACKGROUND ON AUDIT SUPPLIED BY AUDITEE]

Table of Contents

1. Risk Ranking...................................................................................Page 4

2. Details of Situations and Management Initiatives .......................Page 6

3. Follow-up Notices ..........................................................................Page 8

RISK ASSESSMENT RATING REPORT

Review of

Audit Report #

Five Point Risk Rating Scale ranges from:1 = Highest Risk, 2 = Moderately High Risk, 3 = Moderate Risk,4 = Moderately Low Risk and 5 = Lowest Risk

Risk Exposure - Improvement Opportunities RiskRank

Situation 1

Situation 2

1

2

DETAILS

OF

SITUATIONS

AND

MANAGEMENT INITATIVES

Situation 1

Implication

Management Initiatives

[To be supplied by Management]

Situation 2

Implication



Situation 3

Implication



FOLLOW-UP

NOTICES

F O L L O W – U P N O T I C E # 1- 1 -

Audit: [Audit Area under Review]Audit Date: [Date] Implementation Date: See Below

(Date decided by Auditee)

(To be completed by Auditee Management and returned to Audit Services by the Implementation date.)

Responsible Accept ImplementationOfficial(s) Yes (Y)/No (N) Dates

Management Initiatives # 1:

Management Comments:

F O L L O W – U P N O T I C E # 2- 2 -




Responsible Accept ImplementationOfficial(s) Yes(Y)/No(N) Dates



Signed:__________________________Auditee Management/Date

F O L L O W – U P N O T I C E # 3- 3 -




Responsible Accept ImplementationOfficial(s) Yes(Y)/No(N) Dates



Tab KMONTEFIORE MEDICAL CENTER

The University Hospital 111 East 210th Street Department of Audit Servicesof the Albert Einstein Bronx, New York 10467-2490College of Medicine 718-920-6163 Office

718-231-2724 Fax

Auditee: [Insert Auditee Name]

Auditor(s): [Insert Auditor’s Name]

Audit Date: [Insert Date]

Audit Description: [Name of Audit]

Your candid response to the following questions will assist us in ourevaluation of the effectiveness of our audit process. We ask you to agreeor disagree with some basic statements about the completed audit in yourarea. At the conclusion of the audit, please return the completedquestionnaire to Eugene Porter, Vice President of the Department of AuditServices (DAS).

Scale:1 - Strongly Disagree2 - Disagree3 - Agree4 - Strongly Agree

1) The initial meeting with me and/or my staff at the start of the audit, todiscuss the objectives and the scope of the audit was valuable.

1 2 3 4

2) During the audit the auditor displayed:

a. An understanding of our operations,

1 2 3 4

b. Professional conduct,

1 2 3 4

c. Effective communication skills

1 2 3 4

3) The interruption of my staff and area was kept to a minimum duringthe audit.

1 2 3 4

4) The auditor was timely in advising us of his/her findings.

1 2 3 4

5) The findings were found to be accurate and complete.

1 2 3 4

6) The auditor’s recommendation(s) were practical and cost-effective.

1 2 3 4

7) The auditor’s recommendation(s) resulted in a cost savings orrevenue enhancement for my area.

1 2 3 4

8) The audit effectively covered the key areas of concern in my area.

1 2 3 4

9) The audit report clearly communicated the results of the audit.

1 2 3 4

10) Overall, I found the audit was beneficial:

a. To the department

1 2 3 4

b. To the site

1 2 3 4

c. To Montefiore Medical Center

1 2 3 4

11) Additional comments (The following comments are offered to improvethe audit process)

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

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____________________________ ____________Signature Date

____________________________Position/Title

AOP Template

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