AASHTO/MTAP WINTER MEETING · SAP Written Evaluation and Follow-up Testing Plan Documentation ......
Transcript of AASHTO/MTAP WINTER MEETING · SAP Written Evaluation and Follow-up Testing Plan Documentation ......
Preparing for aDrug and Alcohol Audit
AASHTO/MTAP WINTER MEETING
ROBBIE L. SARLES
RLS & ASSOCIATES, INC.
NOVEMBER 9, 2018
Compliance Audit Process
♦ FTA Drug & Alcohol Compliance Audits
○ Conducted Since 1997
○ 40-50 Grantees Per Year
Approximately 10 State DOTs Per Year
○ Selection
Time Since Last Audit
Proximity to Other Selected Grantees
Red Flags• Complaints
• MIS Reporting Issues
Audit Purpose
♦ Purpose
○ Assess Compliance
Identify and Communicate Areas of Non-Compliance
○ Provide Technical Assistance
Identify Corrective Actions
Identify Resources
Notification
♦ Notification
○ Approximately 6 Weeks Notice of Audit
Telephone Notification
○ Provide Overview of Audit Process
Desk Review Schedule
Submission Deadlines
Identification of Contractors/Subrecipients to be Included in On-Site Review
• Typically Nine Subrecipients—Varies With Size of State
Usually Three Simultaneous Audits
Notification
♦ Notification (Continued)
○ Formal Notification Letter
Draft Agenda• Audit Team Schedules—1 Day On-Site/Subrecipient
» DAPM
» Records Review Audit
» Collection Site Audits
List of Required Information for Desk Review
Notification
♦ Lessons Learned
○ Don’t Attempt to Negotiate Dates Unless Absolutely Necessary
○ Don’t Attempt to Negotiate Timeline Unless Absolutely Necessary
○ Ensure All Key Participants Are Available and Understand Importance of Participation
If Unavailable, Obtain Qualified Substitution
Desk Reviews
♦ Desk Review—Preparation
○ Notify Appropriate Participants ASAP
Notify Key Individuals in Agency of Audit• Roles for Compiling Desk Review Information
• Requirements for Participation During On-site Visit
Notify Selected Contractors/Subrecipients• Roles for Compiling Desk Review Information
• Requirements for Participation During On-site Visit
Notify Service Agents• Roles for Compiling Desk Review Information
• Requirements for Participation During On-site Visit
Desk Reviews
♦ Desk Review—Preparation
○ Prepare Pre-Audit Package—Approximately Four Weeks
Policy—Updated• Model Policy
• Individual System Policies
Spreadsheets with Testing Data By Category of Test
Service Agent Contact Information• Up to Date
• Facilitate Scheduling As Needed
Completed Schedule
Desk Review Preparation
♦ Lessons Learned
○ Meet All Deadlines
○ Ensure Information and All Attachments and Download/Uploads Send
○ If Data Request Doesn’t Apply or Information Doesn’t Exist, Don’t Leave Blank
○ If Data is Missing, Provide What You Have and Explain When the Additional Information Will Be Sent
Desk Review Preparation
♦ Lessons Learned
○ If Information is Missing, But Can Be Retrieved From Other Sources, Instruct the Subrecipient to Do So
○ If Issues are Identified, Consult with the Subrecipient to Make Sure Correct Information was Reported
○ Correct Information As Appropriate
Notes to File
Correction Affidavits
Desk Review Preparation
♦ Lessons Learned
○ If Compliance Issues are Found That Cannot Be Corrected, Instruct the Subrecipient to:
Acknowledge
Don’t Attempt to Cover Up
Don’t Alter Records or Files
Create Standard Operating Procedures to Avoid Same Problem in the Future
Desk Review Preparation
♦ Lessons Learned
○ Hopefully, No Surprises
○ Provides Opportunity to Take Proactive Approach to Past Mistakes
Desk Review Conducted
♦ Audit Team Leader Will Review Materials Submitted
○ Policy
○ Test Data Analysis
○ Interview MROs and SAPs
○ Make Follow-up Information Requests
Incomplete
Unclear Information
○ Additional Data Requests
Desk Review Conducted
♦ Audit Team Leader—One Week Prior to On-Site Visit
○ Final Audit Schedule is Provided
Re-Confirm with All Key Participants
Encourage Everyone to Be On-Time and Prepared
○ Sample of Records Identified for Review
Compile All Necessary Information in Advance of Review
• Complete and Accurate
Require All Contractors/Subrecipients to Compile All Necessary Information in Advance
Prior to Site Visit
♦ Lessons Learned
○ Best Practice—Conduct Webinar or Hold Informational Session with Agencies
Review Audit Process and Timeline
Describe Best Practices for Preparation
Become Familiar with Questions
Answer Questions
○ Confirm All Credentials Are Current
List Serve Subscriptions
Credential Documentation
Prior to Site Visit
♦ Lessons Learned
○ Review Desk Review Materials Well In Advance
Assist with Record Organization and Prep
○ Conduct Mock Audits
Can Be Very Helpful But Can Also Confuse Subrecipients and Service Agents
○ Reduce Anxiety
Acknowledge Problems Will Still Occur
Cannot Roll Back the Clock
Some Issues Can Not Be Corrected
Prior to Site Visit
♦ Encourage DAPM and Service Agents to do Homework
○ Regulations
○ Newsletters
○ Policy
○ Urine Specimen Collection Guidelines/Videos
♦ Collection Site Preparation
○ Focus and Serious Nature of Review
○ Collection Process Review/Training
On-Site Visits
♦ Entrance Interview
○ Introductions
○ Overview of Audit Process and Schedule
○ Technical Assistance Focus
○ Serious But Non-Threatening
♦ DAPM Interview and Records Review May Occur Simultaneously
On-Site Visits
♦ Auditors Are Very Knowledgeable About the Regulations
♦ View As Technical Assistance—They Want to Help You Be Compliant!
♦ Approachable
○ Ask Questions and Seek Clarification
○ Relational
♦ Audits Are Not Punitive—Focused on Future
♦ Be On-time
○ Coordinate Schedule
♦ Ensure Appropriate Staff is Present
○ DAPM/Other Appropriate Staff
Most Knowledgeable About Program and Records
Ensure Everyone Is At One Location
♦ Minimize Distractions
On-Site Visits
On-Site Visits
♦ Be Candid
○ Own What you Don’t Know
○ Ask Questions
○ Avoid Statements—”Well I guess I would . . . “
Auditor Workspace
♦ Provide Auditors with Workspace
○ Comfortable
○ Private (to the extent possible)
○ Lockable
○ Power Outlets
○ Beverages, Donuts, Snacks Are Not Necessary
Subrecipient
♦ Subrecipient if Different from Service Provider Should Be in Attendance
○ Documentation of Oversight?
○ Contract Language
DAPM Interview
♦ Be Prepared
○ Review Questions In Advance—Open Book Test
○ If You Don’t Know the Answer During the Audit—Say So
Don’t Guess Or Try to Bluff Your Way Through a Question
Explain That You Will Research to Find Out• Regulations—Have Readily Available in Hard Copy or
Electronic Format
• Implementation Guidelines and Newsletter
• Websites
• State DOT Representative
DAPM Interview
♦ Own Mistakes
○ Be Candid and Forthcoming
○ Do Not Try to Hide or Cover Up Mistakes!
♦ If DAPM Responsibilities Are Provided by Multiple People—Likely that All Will be Interviewed
♦ The Executive Director May Not be the Best Person to be Interviewed
DAPM Interview
♦ Common Findings
○ DAPM Lacks Knowledge of Regulatory Requirements
○ Inadequate Training
○ Missing Inquiries into Employee’s Testing History
Policy
♦ Make Sure You Have Most Updated Policy
○ What Is the Date?
When Was It Approved By Your Governing Board?
Do You Have Documentation?
○ DAPM Should Be Very Knowledgeable About Policy
Re-read and Highlight Sections as Appropriate
Don’t Guess; Consult Policy if Unsure
Know What is Included Under FTA Authority and What is Included Under Your Agency’s Authority
Policy
♦ Areas of Concern
○ Updated Definitions
○ Updated Contact and Service Agent Information
○ Consequences—Consistently Followed
Zero Tolerance
Second Chance
○ Test Refusal Definitions
○ Self-Referral Provisions
○ Post-Accident Definitions
Policy
○ Clearly Defined Separation of Authority
Part of County Department (FMCSA/FTA/Other)
Post-Accident Thresholds Beyond FTA Minimum
○ Negative Dilute
○ Self Referral Testing
○ Alcohol Positives at 0.04 BAC or Greater
○ Use of Policy Builder May Not Be Guarantee of Compliance
♦ Be Organized—Records, Files, Workspace
♦ Records at One Location
○ Best Practice—Pull All Records That Will Be Reviewed and Have Ready for Auditors
Organize by Audit Question
Place in a Binder or File Folders Properly Labeled and in Order
○ Be Prepared to Show How Records Are Secured
○ For Audit, Have Records Ready in Auditors’ Workspace For Ease of Access and Review
Records Review
♦ Check Records to Ensure All Are Complete—Minimize Seeking Out Records While Auditors Are Present
♦ If Records Are Missing, Identify and Request Duplicate Copies from Collection Site, TPA, MRO as Appropriate in Advance of Audit
♦ Do Not Alter or Manipulate Records To Correct A Problem
♦ Don’t Try to Hide Mistakes—Own Them
Records Review
Records Review
♦ Make Sure All Non-DOT Records Are Separate from DOT Records
♦ If No Documentation—It Didn’t Happen
♦ If Anything Is Unusual
○ Document
○ Document
○ Document
Records Review
♦ Additional Record Requests
○ More Than Identified in Original Sample
○ Outside of the Period Originally Selected
○ Additional Written SOP or Forms Utilized
Records Review
♦ Pre-Employment
○ Previous Employer Record Checks
Previous DOT Regulated Employers—2 Years
Applicant Pre-Employment Positive Test
All Safety-Sensitive Positions
○ Pre-Employment Tests
Notification of FTA Authority
Negative Test Result Received Prior to Performance
Records Review
♦ Pre-Employment 90 Day Rule
○ Out of Random Selection Pool
○ No Performance for 90 Days or More
○ Pre-Employment Test
○ No More Than 90 Days Between Negative Result and First Safety-Sensitive Duties
♦ Pre-Employment Alcohol Testing If Conducted
Records Review
♦ Pre-Employment Common Findings
○ No Test Record at All
○ No Previous Employer Record Checks
○ Employ Performs Safety-Sensitive Duties Prior to Receipt of Negative Test Results
Records Review
♦ Random Testing Spreads
○ Plot Day of Week, Time of Day, Time of Testing Period
Unpredictable
Compare with Work Shifts
Provide Explanation of Excusals—Valid and Documented
○ Selection Documentation
Obtained in a Timely Manner—Prior to Testing Period
Records Review
♦ Random Testing Common Findings
○ Limited Spread
Lack of Weekend
Lack of Early Morning/Late Night
Excusals for Invalid Reasons or Not Appropriately Documented
Poor Random Selection List Management
Records Review
♦ Reasonable Suspicion
○ Determination Based on Specific, Contemporaneous, Articulable Observations
○ Performed by Trained Supervisor
○ Documentation
○ Timeline
Test Delays—2 hours
Alcohol Test—8 hours
Records Review
♦ Reasonable Suspicion Common Findings
○ Were Thresholds Met?
Records Review
♦ Post-Accident Records
○ FTA Criteria Met
○ Post Accident Decision Documentation/Form
○ CCFs/Corresponding Accident Reports
○ Time Limits
Documentation of Delay—2 hours
Alcohol Test Limit—8 hours
Drug Test Limit—32 hours
Records Review
♦ Post Accident Common Findings
○ Don’t Meet Testing Criteria
○ Testing Even Tough Discounted as a Contributing Factor
○ Decision Not to Test Insufficiently Documented
○ Delays in Testing Not Documented
Records Review
♦ Return-to-Duty and Follow-up
○ SAP Written Evaluation and Follow-up Testing Plan Documentation
○ Follow-up Testing Plan Followed
○ Negative Return-to-Duty Test Prior to Returning to Safety-Sensitive Duties
○ All Tests Under Direct Observation
Records Review
♦ Return-to-Duty and Follow-up Common Findings
○ Testing Does Not Follow SAP Plan
Records Review
♦ Training Records
○ Records for All Supervisors That Have Had Reasonable Suspicion Training
○ Records for All Safety-Sensitive Employees Demonstrating Completion of Substance Abuse Awareness Training
Records Review
♦ Record Retention Common Findings
○ Length of Time Records Are Maintained
Meet Minimums
Records Review
♦ Review CCF/ATF Sample for Completeness and Accuracy
○ Shadows
○ Missing Information
○ Times of Drug and Alcohol Tests
♦ Require Correction Affidavits as Appropriate
Records Review
♦ CCF/ATF Review Common Findings
○ Non-DOT Tests Separate From DOT Tests
Post-Accident Tests
○ Not Completed Correctly
○ Shadows
Collection Site Review
♦ Notify Collect Sites in Advance of Review
○ Importance of Review
○ Thoroughness of Review
2 – 3 Hours
Mock Collection and Follow-up Interview Questions• Urine Specimen Collector
• Breath Alcohol Technician
Review Calibration Checks, QAP, Training and Documentation of EBT
○ Requirement of Regulation
Access to Facility, Records, and Staff
Collection Site Review
♦ Be Cooperative
♦ View as Free Training/Technical Assistance
♦ Can Select Best Collector
○ Trainer
♦ Be Prepared for Both the Drug and the Alcohol Test
○ Conduct Alcohol Test First During Mock Collection
Collection Site Review
♦ Instruct to Be Prepared
○ Review Questions
○ Refresh Procedures for Eventful Testing Circumstances
Temperature Out of Range
Insufficient Volume
Adulterated Specimen
Collection Site Review
♦ Review Direct Observation Procedures
○ Do Not Guess
○ Use Reference Materials/Guidelines
Provide Copy of “Updated Urine Specimen Collection Guidelines”
○ Go to ODAPC Website
○ Review CCF Completion Procedures
Steps 1, 2, 3, 4, 5
○ Address Issues Found During Employer’s Records Review
Collection Site Review
♦ Ensure Facility Meets Standards
○ Instruct Collection Site to Review and Prepare
Bluing Agent
Water Secure
Potential Contaminants/Adulterants Out of Privacy Enclosure
• Ceiling tiles
♦ DAPM Should Be Present, if Possible
Collection Site Review
♦ Urine Specimen Collection Common Findings
○ Steps Completed Out of Order
○ Confused on Non-Routine Collections
○ Inadequate Shy Bladder Procedures
Collection Site Review
♦ EBT Calibration/Inspection Log Is Available for Inspection
♦ EBT Calibration Checks Are Up to Date and Complete
♦ Time Change Has Been Made on EBT Clock
♦ EBT Quality Assurance Plan Is Readily Available
Collection Site Review
♦ Review ATF Completion Process
♦ Review Fatal Flaws
Collection Site Review
♦ Mock Breath Collection Common Findings
○ Failure to Conduct Alcohol First
○ Unaware of Causes of Cancelled Tests
○ Procedures Between Initial Screen and Confirmatory Test
SAP and MRO Review
♦ Notify SAP and MRO in Advance
○ Explain Importance of Audit
FTA Regulations
○ Participation Is Required by the Regulation
Must Set Aside Enough Time
○ Encourage Preparation
Provide Audit Questions
○ Encourage Responsiveness
SAP and MRO Review
♦ Notify SAP and MRO in Advance (Continued)
○ Make Sure Credentials Are Available
Meet Minimum Standards
List of Two
Exit Interview
♦ DAPM and Other Management Personnel Participate as Appropriate
♦ Auditors Provide a Verbal Debriefing of Deficiencies
♦ Employer May Ask for Clarification
♦ May Ask for Corrective Action Suggestions or Examples
Exit Interview
♦ Final Report Presented
○ Audit Findings Will Not Be Removed—No Surprises
○ Report Format and Key Findings
○ Exceptions Report
○ 90 Day Response Period
Employer Describes and Documents Corrective Actions Taken
• Policy, SOP, Re-training
Audit Follow-Up
♦ Electronic Submission
♦ Call With Questions, Requests for Clarification, or Problems
♦ Submit as Issue Is Resolved
○ Do Not Need to Wait for 90 Days
○ Do Not Need to Submit All at Once
♦ Meet All Deadlines
Audit Follow-Up
♦ Audit Responses Reviewed by Team Leader
○ Issues Letter
Compliance
Continuing Concerns
○ Compliance Letter Formally Closes Out the Audit
○ On-Going Support
Questions?