Audit Report on the New York City Health + Hospitals’ Controls over Inventory of Medical Surgical Supplies Including Personal Protective Equipment at Its Post-acute and Long-term Acute Care Facilities

Executive Summary

This audit was conducted to determine whether New York City (City) Health + Hospitals (H+H)^[1] ensures that its facilities comply with applicable inventory rules and guidelines regarding its management of personal protective equipment (PPE) and other medical surgical supplies.

H+H is a public benefit corporation and is the largest municipal health system in the country. H+H manages five post-acute/long-term care facilities (facilities) that operate as licensed nursing homes and are required to follow New York State Department of Health (SDOH) regulations.

PPE falls under six general categories—gloves, gowns, shoe covers, face shields, caps, and masks (surgical and N95). H+H utilizes a computer-based program called PeopleSoft to manage their medical surgical inventory, including ordering and end user distribution, as well as the management of inventory records of medical surgical items.

The total medical surgical supply purchases for the five facilities for Fiscal Year 2021 totaled $11,474,698.27.

Audit Findings and Conclusion

H+H has established several inventory rules and guidelines relating to the supply and management of medical surgical supplies at its facilities. However, the agency does not ensure that its facilities comply with those rules and guidelines.

Auditors visited all five facilities, conducting a PPE count at one (Carter) and observing a year-end count at another (Coler). At both facilities, the auditors identified deficiencies which are discussed in the body of this report. In its response, H+H noted that this audit was conducted during the height of the pandemic and that H+H’s facilities were significantly impacted by the public health emergency.  The auditors acknowledge the difficult circumstances under which H+H was operating at various points during the audit scope period. Recommendations for improvement are nonetheless offered in the interest of improving processes for the future.

Audit Recommendations

The audit makes four recommendations that will help H+H ensure that its facilities comply with applicable rules and guidelines regarding its management of medical surgical supply inventory. These appear in the body of this report.

Agency Response

In its response, H+H agreed to implement the audit’s recommendations.

[1] Formerly known as the Health and Hospitals Corporation.