Father Saturnino Urios University

ACCOUNTANCY PROGRAM
Butuan City

The Manuel J. Santos Hospital Housekeeping Department

Internal Audit Charter

PURPOSE:

A compliance audit is a program-specic audit or an organization-wide audit of an entity's

compliance with laws, regulations, rules, and provisions of contracts or grant agreements
applicable to government programs with which the entity is required to comply (AICPA, 2010).
The internal audits purpose is to help Manuel J. Santos Hospitals Housekeeping Department
achieve its objectives by ensuring compliance with legislative requirements and other
regulations administered by the Department of Health (DOH), Department of Labor and
Employment (DOLE), Environmental Management Bureau (EMB), and by the administration of
Manuel J. Santos Hospital. Should there be no available standards established by local agencies
for certain functions of the department, the auditors will use standards followed in foreign
countries while keeping in mind its applicability to the setting of Manuel J. Santos Hospital.

AUTHORITY:

The Internal Audit Team (IAT) is a group of fourth year students from the Accountancy Program
of Father Saturnino Urios University entrusted with the function of evaluating the extent of the
departments compliance in accordance to the legislative requirements and other regulations
set by the Department of Health (DOH), Department of Labor and Employment (DOLE),
Environmental Management Bureau (EMB), and by the administration of Manuel J. Santos
Hospital. Also, as mentioned earlier, the auditors will use standards followed in foreign
countries for certain functions of Manuel J. Santos Hospitals Housekeeping Department
wherein no standards are established by local agencies.

The internal audit team, with strict accountability for confidentiality and safeguarding of
records and information is authorized with full, free, and unrestricted access to the following
areas of evaluation:

5S of Good Housekeeping of the Manuel J. Santos Hospital - Housekeeping Department

Hospital Cleaning and Disinfection:

1. Cleaning checklist procedures
1.1 Occupied room
1.2 Vacant room
 1.3 NOC
2. Hand Washing Procedures
3. Waste Segregation and Disposal
4. Cleaning Procedures
4.1 Vacant room
4.2 Occupied room
4.3 Toilet and bathroom/comfort room
4.4 Communal comfort room
4.5 Blood/bloody fluids
5. Floor Mopping Procedures
5.1 Mop head color coding
5.2 Floor mopping
5.3 Mop head washing
6. Rug Washing Procedures
7. Bed Cleaning Procedures
7.1 Bed and mattresses
7.2 Bed making
8. Parking Area Cleaning Procedures
9. Suction Machine Cleaning Procedures

Linen and Laundry:

1. Workplace requirements and engineering controls
2. Personnel requirements
2.1 Training and education
2.2 Personnel's health
3. Personnal protective equipment
4. Linen processing
4.1 Preparation of soiled linen for collection
4.2 Collection and delivery of linen
4.3 Unloading and storage of soiled linen at laundry premises
4.4 Sorting of soiled linen
4.5 Storage and delivery of clean linen
5. Linen decontamination, disinfection and washing requirements
6. Special laundry situations
7. Quality control

Transfer of Patients within the Hospital:

1. Methods of Transfer
2. Transferring of Deceased Patients
3. Transferring Heavier Patients
4. Personal Safety During Transfer
5. Equipment
6. Infection Control
The internal audit team will not evaluate those areas that constitute high risks such as the
Intensive Care Unit (ICU), Isolation Rooms, Laboratories, Emergency Room and Operating
Rooms. However, if possible, the Emergency Room and Operating Rooms would be evaluated.
The internal audit team, with strict accountability for confidentiality and safeguarding of
records and information is also authorized with full, free, and unrestricted access to the
departments documents excluding financial matters that are pertinent in carrying out the
engagement. Personnel in charge are requested to assist the internal audit activity in fulfilling
its audit objective. The members of the audit team report functionally to their instructor and to
the management of Manuel J. Santos Hospital Housekeeping Department.

HOUSEKEEPING DEPARTMENT:

The engaged audit team will report functionally and operationally to the housekeeping
department.

The housekeeping department will:

Approve the internal audit charter
Approve the internal audit plan
Communicate with the Internal Audit Team with regards to the internal audit
activitys performance relative to its plan and other matters.
The audit team will communicate and interact directly with the housekeeping department.

INDEPENDENCE AND OBJECTIVITY:

The internal audit activity will remain free from interference by any element in the organization
to permit maintenance of independence and objective mental attitude. Internal auditors will
have no direct operational responsibility or authority over any activities audited. The auditors
will exhibit the highest level of professional objectivity in gathering, evaluating and
communicating information about the activity or process being examined. Internal auditors will
also make balanced assessment of all the relevant circumstances and not be unduly influenced
by their own interests or by others in forming judgments.

PROFESSIONALISM:

The internal audit team will conduct itself with adherence to the Institute of Internal Auditors
mandatory guidance including the Definition of Internal Auditing, the Code of Ethics, and the
International Standards for the Professional Practice of Internal Auditing. This mandatory
guidance constitutes principles of the fundamental requirements for the professional practice
of internal auditing and evaluating the effectiveness of the control procedures for the operation
of the internal audit activitys performance. The Institute of Internal Auditors Practice
Advisories, Practice Guides, and Position Papers will also be adhered to as applicable to guide
operations. In addition, the internal audit team will adhere to the housekeeping departments
relevant policies and procedures.

RESPONSIBILITY:

The scope of internal auditing encompasses the following:

Determining the quality and effectiveness of Manuel J. Santos Hospital
cleaning for the areas of evaluation with accordance to the legislative
requirements and other regulations set by the Department of Health (DOH),
Department of Labor and Employment (DOLE), Environmental Management
Bureau (EMB), and by the administration of Manuel J. Santos Hospital. This
includes foreign standards as mentioned earlier.
The internal auditors are bound to make a compliance audit report comparing
the actual observations with the standard requirements, as well as the
recommendations provided by the said auditors for the overall betterment of
Manuel J. Santos Hospital Housekeeping Department.
Internal auditors are obliged to conduct the audit engagement accordingly so
as to preserve their integrity, objectivity and competency, as well as in
observing utmost confidentiality in whatever situation maybe.

AUDIT PROCESS APPROACHES:

1. Entrance Conference
A meeting will be held between the internal audit team and the head staff of the
Housekeeping Department of Manuel J. Santos Hospital. The audit team will
discuss the purpose of the audit, the time period included in the audit, and
resources needed. The management will be given the opportunity to discuss any
concerns or queries about the audit.
2. Preliminary Survey
During the preliminary survey, the auditors will interview personnel concerning
their duties and responsibilities, observe day-to-day operations, flowchart
processes and draw preliminary conclusions. Based on the preliminary survey, an
audit plan will be prepared to carry out field work.
3. Internal Audit Planning
The audit team will submit to the management an internal audit plan for review
and approval and will communicate the impact of resource limitation and relevant
changes whenever there are significant findings needed to be addressed to the
management during the conduct of audit activity. The internal audit plan will be
developed based on the prioritization by using specified audit program. The Chief
Audit Executive will review and adjust the plan, in response to any changes in the
organization. Any significant changes from the approved audit plan will be
communicated to the management through periodic activity report.
 4. Field Work
The internal audit team will physically be on site at the audit clients location
performing the audit. The following are some of the procedures generally
performed during fieldwork:
o Review the supporting documentation
o Interview department personnel
o Interview administrative officer
o Perform analyses
o Identify limitations to the audit activity
o Identify recommendations for improvement
o Prepare written audit comments (i.e., findings)
o Department provides written response and corrective action plan
for findings
5. Report Draft
Once the fieldwork is completed, the audit team will synthesize an audit report
that reflects what was done, what was found, and any recommendations for
improvement.
6. Exit Conference
A meeting will be held between the internal audit team and the management of
Manuel J. Santos Hospitals Housekeeping Department to discuss the audit
findings before the findings is officially released. The management will be allowed
to agree or disagree with the findings but must present evidences to support the
non-concurrence with the auditors. Any recommendations by the auditors for
improvement or corrective action are also discussed at this time.

REPORTING:

A written report, to be prepared and issued by the Chief Audit Executive, will be given to the
housekeeping department and to the instructor. The internal audit report must include
managements response and corrective action taken or to be taken in regard to specific findings
and recommendations.

RECOMMENDATIONS:

The internal audit team will provide recommendations based on the conducted compliance
audit. The recommendations are expected to add value to Manuel J. Santos Hospital
Housekeeping Department. During the formulation of the recommendations, its feasibility will
be taken into consideration by the internal audit team.

The Chief Audit Executive will communicate the results to the housekeeping department head
and to the instructor.
KIRBY P. JOSOL
Chief Audit Executive

MR. DENNIS B. PEALOSA DR. EVANGELINE P. JAMILI

Housekeeping Department Head Program Dean