Thomas P. DiNapoli
COMPTROLLER

OFFICE OF THE
NEW YORK STATE COMPTROLLER
DIVISION OF STATE
GOVERNMENT ACCOUNTABILITY

Audit Objective............................... 2
Audit Results - Summary............... 2
Background..................................... 3
Audit Findings and
Recommendations....................... 3
Verification of Plan Activities.......... 3
Recommendation .............................. 4
Verification of Grant Activities........ 5
Recommendations............................. 6
Audit Scope and Methodology....... 6

NEW YORK CITY
DEPARTMENT OF HEALTH
AND MENTAL HYGIENE

FLU PANDEMIC
PREPAREDNESS

Authority ......................................... 7
Reporting Requirements................ 7
Contributors to the Report ............ 7
Appendix A - Auditee Response .... 8
Appendix B - State Comptroller
Comments .................................. 12

Report 2007-N-19

 AUDIT OBJECTIVE
Our objective was to determine whether the
New York City Department of Health and
Mental Hygiene (DOHMH) has been actively
preparing for a flu pandemic.
AUDIT RESULTS - SUMMARY
Influenza (flu) viruses have threatened the
health of animal and human populations for
centuries. A flu pandemic occurs when a new
strain of influenza emerges that has the ability
to infect and be passed between humans. We
found that DOHMH has been actively
preparing for a flu pandemic and has
developed a comprehensive plan (Plan) to
outline its activities and guide its efforts.
However, we also note that not all Plan
activities reportedly completed by DOHMH
have
been
documented.
Further,
improvements are needed over certain
inventory items to ensure that they are readily
available for distribution in the advent of a flu
pandemic.
In July 2006, DOHMH released its Pandemic
Influenza Preparedness and Response Plan
(Plan) to guide the New York City’s (City)
response efforts in the event of a flu
pandemic. To assist it in its flu pandemic
preparedness efforts, DOHMH received $5.8
million in grant funding from the Centers for
Disease Control and Prevention (CDC) and
$1.9 million in grant funding from the United
States Department of Health and Human
Services (Health and Human Services).
We identified a total of 154 Plan activities
ranging from the purchase and distribution of
supplies and medical equipment, to
conducting exercises that test response
scenarios. Of these, we judgmentally selected
20 of the 154 activities, spanning various Plan
categories, to determine whether these various
activities had been completed. Of the 20

Report 2007-N-19

sampled activities, we verified that 18 were
adequately documented as completed.
For the two remaining sampled Plan
activities, DOHMH could not provide us with
adequate supporting documentation to verify
that certain required materials, including flu
diagnostic test kits and rapid testing kits, were
distributed to their intended destinations such
as hospitals, clinics and physician’s offices.
Although receipt of these items was
eventually acknowledged by the intended
recipients, it was done long after the reported
distribution date and only in response to a
DOHMH inquiry.
DOHMH’s application forms for grant
monies include a description of the pandemic
flu-related
activities
DOHMH
would
complete with the requested grant funds. To
verify that the noted grant activities were
completed, we judgmentally selected five of
the 29 activities listed on the Health and
Human Services grant application, and 14 of
the 27 activities listed on the CDC grant
application. We found that DOHMH
completed the sampled grant-related activities
as described.
We also note the need for improved controls
over the inventory of face masks. DOHMH
had not performed a physical inventory to
confirm receipt of 216,000 face masks stored
in warehouse space located in the State of
Delaware.
Our
audit
report
contains
three
recommendations regarding documentation of
Plan and grant-related activities, and
inventory controls.
In response to our draft audit report DOHMH
officials agreed with two of our
recommendations and disagreed with the
remaining recommendation.

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 This report, dated August 13, 2009, is
available
on
our
website
at:
http://www.osc.state.ny.us.
Add or update your mailing list by contacting
us at: (518) 474-3271 or
Office of the State Comptroller
Division of State Government Accountability
110 State Street, 11th Floor
Albany, NY 12236
BACKGROUND
Influenza (flu) viruses have threatened the
health of animal and human populations for
centuries. A flu pandemic occurs when a
novel (new) strain of influenza emerges that
has the ability to infect and be passed between
humans. Because humans would have little
immunity against the new virus, a worldwide
epidemic, or pandemic, can occur. Flu
pandemics have occurred three times since
1900 (1918, 1957, and 1968), killing millions
of people worldwide.
Preparing and planning responses to
pandemics is taking place at all levels of
government. Federal plans, strategies or other
guidance have been issued by the United
States Homeland Security Council, United
States Department of Health and Human
Services (Health and Human Services), and
the Centers for Disease Control and
Prevention (CDC).
In July 2006, the New York City (City)
Department of Health and Mental Hygiene
(DOHMH) released its Pandemic Influenza
Preparedness and Response Plan (Plan) to
guide the City’s response effort in the event
of a flu pandemic. Many City agencies would
be involved in a pandemic response,
particularly the Office of Emergency
Management, the Health and Hospitals
Corporation, the Police Department, the Fire
Department, and the Department of Citywide
Administrative Services. In preparing its Plan,

Report 2007-N-19

DOHMH used the U.S. Department of
Homeland Security’s National Strategy for
Pandemic Influenza Implementation Plan,
issued in May 2006, and the U.S. Department
of Health and Human Services’ HHS
Pandemic Influenza Plan, issued in
November 2005, as models for its own Plan.
To assist it in its flu pandemic preparedness
efforts, DOHMH has received $5.8 million in
grant funding from the CDC, and $1.9 million
in grant funding from Health and Human
services.
AUDIT FINDINGS AND
RECOMMENDATIONS

Verification of Plan Activities
DOHMH’s Plan describes the detailed
pandemic planning and response activities
expected of DOHMH, as well as other City
health care providers such as hospitals and
clinics. DOHMH officials stated that the Plan
has been a work in progress and will be
continually updated as new information
becomes available.
The Plan lists nine strategic planning areas:
Command, Control, and Management
Procedures; Surveillance and Epidemiologic
Response;
Laboratory
Diagnostics;
Community Control and Response; Health
Care Planning and Emergency Response;
Delivery of Antiviral Drugs; Vaccine
Management; Mental Health Response; and
Communications.
Each planning area contains various activities
that are necessary for completion in order for
the City to be properly prepared. We
identified a total of 154 activities ranging
from the purchase and distribution of supplies
and medical equipment, to conducting
exercises that test response scenarios. We
judgmentally selected 20 of these activities,

Page 3 of 12

 spanning various Plan categories, to
determine whether they had been completed.
Of the 20 sampled activities, we verified that
18 were completed and fully documented. For
example: One sampled activity required
DOHMH to train the staff at 66 New York
City hospital and commercial laboratories to
perform influenza testing and shorten the time
for recognition of an outbreak, while another
activity required “tabletop exercises” for
hospitals to use in testing their bio-event
emergency response plans.
Yet another
activity required the purchase and distribution
of vents and durable medical supplies for preselected hospital facilities to enhance surgical
capacity in the event of an outbreak. We
were able to verify that these activities had
taken place.
However, for the following two activities,
DOHMH could not provide us with adequate
supporting documentation to verify that they
had taken place:


The Plan required flu diagnostic test
kits to be provided to 30 different
community health clinics, hospitals
and private physician practices to
perform flu testing. DOHMH records
report the kits being distributed during
December 2005. We found that the
procedures used by DOHMH to verify
delivery of these kits were not
formalized and, as a result, there were
no receipts of test kit delivery on file.
As a result, there is inadequate
assurance that the test kits were
appropriately distributed or the
associated testing performed.
In response to our observations,
DOHMH sent out confirmation letters
to all 30 clinics but only received
replies from two clinics that were

Report 2007-N-19

dated May 23, 2008 and May 27,
2008. These two clinics indicated that
they had received the flu diagnostic
test kits, but did not specify the dates
received.


The Plan also required DOHMH to
provide 28 sites (clinics and
physicians’ offices) with rapid testing
kits for the 2005 to 2006 flu season so
they could identify whether influenza
A was circulating within their practice
and community. DOHMH provided us
with dated receipts showing that the
rapid testing kits were delivered to 20
of the 28 sites commensurate with the
above-noted time period. For the
remaining 8 sites, DOHMH obtained
letters from the clinics, dated March
24-26, 2008, indicating that the kits
were received but did not note when
they were received. The original
dated receipts of delivery provide
greater assurance than reliance on
after-the-fact correspondence that is
unclear about when the kits were
obtained.

The earlier a potential pandemic virus is
detected, the earlier action to address the virus
can be taken. Consequently, ensuring these
test kits are distributed and used as intended is
one component of early detection.
(In response to our draft audit report,
DOHMH officials point out that the test kits
are used to identify influenza A. They add
that these test kits will not detect a possible
pandemic flu such as H1N1. They also point
out that the test kits were meant as an
incentive for providers to participate in the
Influenza Sentinel Providers network, which
is a component of DOHMH’s Syndromic
Surveillance System.)

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 Recommendation
1. Maintain documentation for all Plan
activities to verify that each is/was
performed as intended.
(DOHMH
officials
Recommendation 1.)

agree

with

Verification of Grant Activities
To enhance its flu pandemic preparedness
activities, DOHMH applied to Health and
Human Services and CDC for grant monies to
be used specifically for this purpose. The
respective grant applications require a
description of what activities DOHMH would
complete with the grant monies. We found
that DOHMH completed all of the sampled
grant-related
activities.
However,
we
identified a need for improved controls over
face mask inventory purchased with Health
and Human Services grant monies.
Health and Human Services Grant
The $1.9 million award from Health and
Human Services was to be used specifically to
address flu pandemic planning. Detailed
grant application activities include the
purchase of surgical gowns, hand hygiene
products and face masks; and DOHMH staff
visits to emergency departments of local
hospitals to conduct screening and isolation
drills.
To verify that DOHMH performed the listed
grant activities, we judgmentally selected five
of the 29 listed activities, spanning various
grant categories, for review. We found that
the five sampled activities were in fact
completed – including the purchase of special
use face masks. However, we have concerns
regarding the inventory controls over these
masks.

Report 2007-N-19

DOHMH’ grant application stated that 1.1
million face masks would be purchased and
retained to help stop the spread of a possible
flu pandemic. When we asked to see the face
masks in question, DOHMH officials
explained during the audit that the original
grant funding was reduced and they were only
able to purchase 216,000 face masks, at a cost
of $84,396, instead of the originally planned
1.1 million.
According to DOHMH officials, these face
masks were stored in a warehouse located in
the State of Delaware - and the warehouse did
not provide them with a confirmation of the
inventory of face masks on hand. Further,
DOHMH officials informed us that they had
not performed their own physical inventory to
confirm receipt of the masks. As a result,
DOHMH lacked adequate assurance that the
216,000 face masks in the Delaware
warehouse were accounted for.
(In response to our draft audit report,
DOHMH officials assert that the face masks
in question, although pandemic flu-related,
were not purchased with this specific grant.
They subsequently provided us with a
summary of the items purchased with this
specific
grant,
and
the
purchase
documentation for the masks, to support their
assertion. They also indicate that the masks
have been relocated to the New York City
area and that a new inventory tracking system
is being implemented.)
CDC Grant
The $5.8 million award DOHMH received
from CDC outlined 27 activities relating to
planning for a flu pandemic including
planning,
communication,
isolation,
quarantine, and community preparedness and
participation. To verify that the CDC grant
activities were performed, here too we
judgmentally selected 14 of the 27 listed

Page 5 of 12

 activities, spanning various grant activities,
for review. These activities included training,
conducting exercises to test the Plan,
promoting
volunteer
recruitment
and
distributing,
storing,
monitoring
and
administering flu pandemic vaccines. In
addition, DOHMH is to establish agreements
with neighboring jurisdictions that address
communication, mutual aid, and other cross
jurisdictional needs.
We found that DOHMH adequately
documented completion of all 14 sampled
activities as described in the grant application.
Recommendations
2. Verify the existence of the 216,000 masks
procured with pandemic flu-related grant
monies, and relocate them to New York
City.
(DOHMH officials disagree with this
recommendation because they maintain
the masks have been identified and are
now stored in a warehouse in the New
York City area.)
3. Implement a comprehensive inventory
over all products procured with grant
funds including the specialized masks
noted above.
(DOHMH
officials
Recommendation 3.)

agree

with

AUDIT SCOPE AND METHODOLOGY
We audited the various activities being
employed by DOHMH to prepare for a flu
pandemic. Our audit covered the period July
10, 2006 through November 30, 2008.
To accomplish our objective, we met with
DOHMH officials and reviewed DOHMH’s
Pandemic Influenza Preparedness and

Report 2007-N-19

Response Plan (Plan), the U.S. Department of
Homeland Security’s National Strategy for
Pandemic Influenza Implementation Plan, and
Health and Human Services’ HHS Pandemic
Influenza Plan. We also reviewed grant
applications and any and all documentation
available to support the sampled activities
selected for audit. Reviewed documentation
included meeting agendas and minutes,
attendance sheets, inventory records and
purchasing documents.
As is our practice, we notify agency officials
at the outset of each audit that we will be
requesting a representation letter in which
agency management provides assurances, to
the best of their knowledge, concerning the
relevance, accuracy and competence of the
evidence provided to the auditors during the
course of the audit. The representation letter
is intended to confirm oral representations
made to the auditors and to reduce the
likelihood of misunderstandings.
In the
representation letter, agency officials assert
that, to the best of their knowledge, all
relevant financial and programmatic records
and related data have been provided to the
auditors. Agency officials further affirm that
either the agency has complied with all laws,
rules, and regulations applicable to its
operations that would have a significant effect
on the operating practices being audited, or
that any exceptions have been disclosed to the
auditors. However, officials at the New York
City Mayor’s Office of Operations have
informed us that, as a matter of policy,
mayoral agency officials do not provide
representation letters in connection with our
audits. As a result, we lack assurance from
agency officials that all relevant information
was provided to us during the audit.
We conducted our audit in accordance with
generally accepted government auditing
standards. Those standards require that we
plan and perform the audit to obtain

Page 6 of 12

 sufficient, appropriate evidence to provide a
reasonable basis for our findings and
conclusions based on our audit objectives. We
believe that the evidence obtained provides a
reasonable basis for our findings and
conclusions based on our audit objectives.
In addition to being the State Auditor, the
Comptroller
performs
certain
other
constitutionally and statutorily mandated
duties as the chief fiscal officer of New York
State. These include operating the State’s
accounting system; preparing the State’s
financial statements; and approving State
contracts, refunds, and other payments. In
addition, the Comptroller appoints members
to certain boards, commissions, and public
authorities, some of whom have minority
voting rights.
These duties may be
considered management functions for
purposes of evaluating organizational
independence under generally accepted
government auditing standards.
In our
opinion, these functions do not affect our
ability to conduct independent audits of
program performance.

AUTHORITY
We performed this audit pursuant to the State
Comptroller’s authority as set forth in Article
V, Section 1 of the State Constitution, and
Article III of the General Municipal Law.
REPORTING REQUIREMENTS
We issued a draft copy of this report to
DOHMH officials for their review and
comments. Their comments were considered in
preparing this final report and are attached in
their entirety as Appendix A. State Comptroller
Comments on the DOHMH response are
attached as Appendix B.
Within 90 days after final release of this report,
we request the Commissioner of DOHMH to
report to the State Comptroller, advising what
steps were taken to implement the
recommendations contained herein, and where
recommendations were not implemented, the
reasons why.

CONTRIBUTORS TO THE REPORT
Major contributors to this report include
William Challice, Frank Patone, Al Kee,
Todd Seeberger, Jeff Marks, Ryan
Wendelowski, Unal Sumerkan, Jonathan
Bernstein, Adele Banks and Sue Gold.

Report 2007-N-19

Page 7 of 12

 APPENDIX A - AUDITEE RESPONSE

*
Comment
1

* See State Comptroller Comments, page 12.

Report 2007-N-19

Page 8 of 12

 Thomas P. DiNapoli -2- 

Additional comments on the draft audit roport are i11qude in the 1'oapon55 which
supports our position.

We: appreciate the courtesy and professionalism of your staff in their porfmmanoo of this
audit. If you have quosticms or need ?n?ihor information, pleaso nonmot Thomas Hai'diman,

Internal and External Audits, at 212-219-5235.

Sincaloly,

 

CC: Thomas Parlay, MD, MPH
Andrew Rein
Isaac Weis?ise, MD, 
Sara Pachnan
Thomas Hardiman

Report Page 9 of 12

RESPONSE TO THE NEW YORK STATE AUDIT OF THE
DEPARTMENT 0F HEALTH AND MENTAL HYGIENE FLU 
PREPAREDNESS

(mill-N49)

This response to ?ndings and along with the attached cover letter
constitute formal response to the Of?ce of the Comptroller?s draft report titled
New York City Department ofHeaith and Men/ta! Hygiene: Pandemic Flu Preparedness
(?Report?) dated May IS, 20139. We acknowledge the Work and dedication oflyonr staff during
the performance of this audit.

The audit?s objective was to determine whether has been activer preparing for a
flu pandemic?. We are pleased that the auditors concluded that has been actively
preparing for a ?u pandemic and has developed a comprehensive plan to outline its activities
and that guides its e?orls.

The auditors made three recommend ati one. We agree with the two that
should 1) maintaining documentation for all Plan activities and 2) implement a
comprehensive inventory controls over all products. As acknowledged in the audit report,
is procuring a new inventory system, which will commence operation in FY 21] it}.
However, we disagree with the third recommendation should ?verify the
existence of 216,000 masks pmcured with pandelm'c Hui-related grant; monies and relocate
them to New York City?.

In the following sections, we ?rst focus on the Audit Results- Summary section where we
explain why this recommendation should be removed from the report and suggest an
additional change for clarity. We will then respond to each recommendation.

Audit Results Summaryr 216,000 Face Masks

 

In the Audit Results Summary, the auditors state that could not roadin identify 
215,000 face masks purchased with grant funds.? The auditors also state that the masks . .would 00 
not he readin available to New Yorkers, including ?rst responders, until transported to the New 2

York City ales." These statements should he removed from the report for the following reasons:

 

 

 

The masks have been identi?ed and are now located in a CDC approved New
York City area warehouse which is easily accessible to NYC. These masks were not
purchased with Pandemic Flu related monies. They were procured under a separate grant
program, Assistant Secretary,r for Preparedness and Response (ASPE), for hospital
plepared sees for all emergencies._

- In August 2903, we explained to the auditors that these masks were procured with a
separate program grant funds and provided them with pl'cofcf purchase of 2ld,iltlil
masks and their shipment from a Delaware warehouse. We have forwarded
documentation of the transfer of these masks to the New York City area warehouse under
a separate cover.

See State Comptroller Comments, page 12.

Report Page 10 of 12

0 The auditors did not visit the warehouse where these masks were stored.
In the event ofe pandemic ?u outbreak, there would be suf?cient timeto transfer the
masks from Delaware to the New York area. As a result, we recommend removing the
statement about the masks not being readily available to New Yorkers.

Veri?cation of Plan Activities Distribution of Diagnostic Test Kits

 

The auditors acknowledged that DOHMH had sought, obtained, and provided the alternative 
documentation to demonstrate that the tost kits were delivered to their intended recipients. We Comment
would like the auditors to include the following paragraph for clarityr about the test kits and their 2
importance:

 

 

 

"The test kits are used to identify in?uenza A. Theses kits will not detect a possible
pandemic flu such as . These kits were meant to serve as an incentive for providers to
participate in the in?uenza Sentinel Providers Newark, which is a component 
Surveillance System."

Rea nose to dit Recommendations

i. Maintain documentatioufor at? Pine activities to that such revives pergformcd as intended
DOHMH Response:

We concur with the auditors? recommendation. Documentation is routinely maintained for all Plan
activities. Occasionally a document is misplaced and the program will take steps to substantiate
activities by using altemativc documentation;

2. Veil-w: the existence ofrnc 216, 0th? musicsprucurad with monies, and
relocate them to New York City.

Response: 
As stated above. the 216,000 masks have been identi?ed. and are now stored in a warehouse in the
New York City area.

3. Implement a comprehensive inventory over of! products pro cured with grant?no?s including the
Specialized musics noted above.

DOHMH Response:

We ale aware of the need to improve inventory controls at warehouse. We are in the
process of implementing a new inventory tracking system, that will include grant purchased
equipment and items. The system is expected to commence operation in FY2010.

See State Comptroller Comments, page 12.

Report Page 11 of 12

APPENDIX B - STATE COMPTROLLER COMMENTS ON AUDITEE RESPONSE
1. It appears that much of the DOHMH
disagreement with this recommendation is
because the 216,000 masks have
reportedly been identified and were
relocated to a New York City area
warehouse in February 2009. We are
pleased that actions have been taken
consistent with our recommendation
developed at the time of our audit.
DOHMH officials also note that the
masks we looked for were not purchased
with the grant in question, but were
purchased with another pandemic-flu

Report 2007-N-19

related grant.
As support for their
response, they subsequently provided us
with a summary of the items purchased
with the audited grant, and the
procurement documentation for the
216,000 masks. Our report has been
revised to reflect these facts.
2. We have revised our final audit report to
reflect the comments of DOHMH
officials.

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