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The Chelsea Soldiers’ Home Did Not Document the Need for Nursing Department Premium Overtime or Properly Maintain Required Nursing Department Overtime Staffing Records.

The Chelsea Soldiers' Home did not have documentation to show the need for or approval of overtime.

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The Chelsea Soldiers’ Home (CHE) nursing department did not document that premium overtime was needed or that members of its nursing staff had requested and received required prior supervisory approval to work the premium overtime reported on their timesheets for any of the 20,664 overtime transactions (totaling $3,320,033) that occurred during our audit period. As a result, there is a higher-than-acceptable risk of CHE incurring unnecessary overtime expenses.

In addition, CHE could not provide any Daily Staffing Schedules for 17 of the 24 months covered by our audit, which represented 14,119 overtime transactions totaling $2,268,038. From the 7 months of Daily Staffing Schedules that CHE could provide, we compared the information related to a sample of 102 overtime transactions to CHE’s Weekly Overtime Summary Forms and found problems. Specifically, the names of 16 nurses on the Daily Staffing Schedules did not appear on the related Weekly Overtime Summary Forms, and the names of 81 nurses on the Weekly Overtime Summary Forms did not appear on the related Daily Staffing Schedules. Also, none of the Weekly Overtime Summary Forms for the 102 transactions had been approved. Without the required records, CHE cannot ensure that all of its overtime payments are proper.

Authoritative Guidance

CHE has an “Overtime Request/Approval Policy” to ensure that all employees have prior approval to work overtime and that overtime hours are not paid if they have not been preapproved by supervisors through the Overtime Request Form. Section 4 of the policy states,

B.   Department Head/Supervisors will be responsible for the approval of overtime. . . .

C.   Request for overtime shall be presented to the Department Head/Supervisor in writing with justification for request. Approval of the request by the Department Head/Supervisor shall also be made in writing to the requestor.

The Overtime Request Form states, “Overtime hours will not be paid if they have not been pre-approved.”

CHE created the Daily Staffing Schedule for use as a daily roster to allocate and track staff members and record overtime, as well as to ensure that the Nursing Department maintains the minimum staffing level for every shift. The Weekly Overtime Summary Form is completed by the overnight nursing supervisors and authorized by the director of nursing. It records who worked overtime, the actual overtime hours worked, the reason for the overtime, the unit where the overtime was worked, the person being replaced (if any), and the supervisor’s initial. By developing these forms and procedures, CHE management demonstrated that written overtime approvals for employees are an important internal control to ensure that all overtime worked is necessary and proper.

Also, Sections D04-03 and D04-05 of the Massachusetts Statewide Records Retention Schedule Quick Guide Schedule Number 06-18, issued by the Secretary of the Commonwealth, describes time and attendance records as follows:

Documents actual hours worked by unit employees and types and amounts of leave taken. Includes time sheets, time cards, attendance forms, absence reports, leave reports, and related correspondence.

D04-03(a):      Fiscal/Payroll Office records.

Retain 6 years.

Reasons for Noncompliance

CHE lacked effective monitoring controls to ensure that it properly documented prior approval for overtime worked and that supervisors properly completed the Daily Staffing Schedules and Weekly Overtime Summary Forms. Also, CHE’s policies and procedures did not address the retention period for payroll records, including Daily Staffing Schedules and Weekly Overtime Summary Forms.


  1. CHE should enhance its policies and procedures by establishing monitoring controls to ensure that it properly documents the need and prior approval for overtime worked and that its supervisors properly complete the Daily Staffing Schedules and Weekly Overtime Summary Forms.
  2. CHE should create policies and procedures to require overtime documentation to be retained for at least six years in accordance with the Massachusetts Statewide Records Retention Schedule.

Auditee’s Response

The Chelsea Soldiers’ Home (CHE) has revised its overtime policy based on the audit findings. The updated policy implements controls to monitor overtime approvals. Overtime approval authority is delegated to nursing supervisors and monitored by the Budget Director. Prior to the COVID-19 pandemic, CHE monitored overtime through monthly overtime review meetings [led] by the Deputy Superintendent. CHE will resume monthly overtime scrub meetings which will review documentation and ensure compliance with procedures. The monthly overtime scrub meetings will be led by the CHE Budget Director.

CHE utilizes Oracle HR/CMS PeopleSoft time and attendance software which is used by Commonwealth agencies to track employee payroll. There are two types of time entries permitted for this system: direct entry, and Time Control Device (TCD) swipe card entry. All the positions listed under “[CHE] Total Earnings by Nursing and Medical Staff Department Position” with the exception of Registered Nurse (RN) V, IV, Physician II/III and Nurse Practitioner must be physically present on-site to swipe their ID badge for their time and attendance to be documented. Only nursing management and supervisors enter their time manually. The rest of nursing staff enter their time through a TCD and they must be physically present to swipe in and out for their shifts. CHE will appoint a dedicated scheduler for the nursing department. This position will allow for the uniform distribution and documentation of overtime within the nursing department. Other responsibilities will include the maintenance of proper documentation of schedules and overtime requests and approvals. Previous efforts to fill this position were not successful.

In conjunction with the position, CHE will procure scheduling software with oversight provided by the Executive Office of Health and Human Services. The intent of the procurement will be to automate the equitable distribution of shifts based on union rules and assigned locations. Scheduling software will also serve as documentation for prior approval of overtime. . . .

All CHE staff will receive training from CHE General Counsel on Commonwealth of Massachusetts Records Retention Policy. CHE will procure a contract for records storage and digitization in conjunction with its Electronic Medical Record implementation. This will prevent loss of critical documentation in the future by ensuring secure digital storage and reduce space requirements onsite for records storage and will facilitate easier retrieval. Departmental Managers will monitor this for compliance.

Date published: March 30, 2021

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