ACAD Audit Checklist

ENVIRONMENTAL PROTECTION AND GROWTH MANAGEMENT DEPARTMENT ANIMAL CARE and ADOPTION DIVISION 2400 SW 42nd Street • Fort Lauderdale, Florida 33312 • 954-359-1313

Broward County Board of County Commissioners

Mark D. Bogen • Beam Furr • Steve Geller • Dale V.C. Holness • Lamar Fisher • Nan H. Rich • Tim Ryan • Barbara Sharief • Michael Udine www.broward.org

ACAD Audit Checklist v. 6.1.21

At the January 12, 2021 Commission meeting, the Broward County Board of County Commissioners requested a checklist demonstrating progress on addressing 1321 recommendations from the County Auditor on improving ACAD operations [see ACAD Audit Report No. 21-05, dated December 16, 2020, and covering fiscal years 2019 and 2020 (through May 31, 2020)]. The checklist below will be updated monthly until further notice.

Recommendation ( - Altered Since Last Report)

A - Implemented B - Under Review or

Development Estimated

Date of Next

Update

Comments

# Description A B

Total1 87 45 66% 34%

1

Recommend management increase ACAD staff by 29.5 to 36 FTE depending on management’s decisions about: ▪The use of volunteers for enrichment, which may reduce proposed staffing by 4 FTEs ▪Hiring or outsourcing behaviorists, which may reduce proposed staffing by 2.5 FTEs

N/A

A new Director of ACAD has been hired and is evaluating all major areas of the Shelter and its programs. The new Director will be working with County Administration on ACAD’s 180-day “reset” plan. Reset plan presented to Board on 5/11/21 recommends six new staff for the 2022 Budget Year.

2 Recommend management evaluate administrative and clerical position staffing for adequacy. N/A

Reset plan presented to Board on 5/11/21 recommends a total of six new staff positions for the 2022 Budget Year.

https://broward.legistar.com/View.ashx?M=F&ID=9033134&GUID=3130B2AC-7A2E-4EB2-B281-65D6FB02B876

ACAD Audit Checklist 6.1.21

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Development

Estimated Date of

Next Update

Comments

# Description A B

3

Recommend management define its capacity for care and update standard operating procedures with protocols to maintain the shelter’s population within this capacity while pursuing the County’s no kill goal.

8/1/2021

Reset plan presented to Board on 5/11/21 made no recommendations on changes for capacity to care. Physical capacity remains at those levels recommended by Best Friends Animal Society, based on the Association of Shelter Veterinarians Guidelines for Standards of Care in Animal Shelters. Procedures are currently being updated to reflect this. Capacity for care will continue to evolve based on program development and staffing levels budgeted.

4

Recommend management monitor the average length of stay for dogs, cats, puppies, and kittens to determine what animals move most quickly out of the shelter and to identify bottlenecks in the animal flow through the shelter. All efforts need to be made to minimize the length of stay for animals with an emphasis on a live release outcome.

N/A

A Phase 1 report was completed including mean and standard deviations to track both length of stay and variability in that metric. This report now accounts for time spent in foster care (and out of the shelter).

5

Recommend management work to create additional community partnerships to decrease average length of stay.

N/A

Management working with over 220 rescue groups and continuing to expand this number and enhance existing partnerships. Management also working with many human services groups to prevent surrender and increase successful reunifications. Also actively working on expanding this number.

6 Recommend management implement all recommendations in the consultant reports to address issues with the HVAC System.

8/1/2021 Construction on the roof and HVAC systems is currently underway. Anticipated completion is Summer 2021.

7

Recommend management review current shelter design and develop a plan for enhancements that would support the County’s “No-kill” goal.

N/A

It is not clear that any redesign is necessary to reach "no-kill." For example, ACAD has already progressed from 75% live release in FY 2018 to 87% live release in FY 2021. A conclusive course of action to this recommendation will be incorporated in the new Director's 180-day “reset" plan. Reset plan presented to Board on 5/11/21 makes no recommendations on shelter redesign, but instead focuses on shelter programming.


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Development

Estimated Date of

Next Update

Comments

# Description A B

8

Recommend management redesign play and enrichment areas to ensure suitability for this purpose. Management should ensure the areas: A. Can be adequately sanitized by considering a mixture of natural grass and synthetic turf. B. Have sufficient shade and protection from inclement weather to facilitate daily operations. C. Are adequately graded or leveled to reduce the risk of fall and injury to employees, volunteers, and members of the public.

3/31/2022

Working with Pets’ Broward to complete the work. Currently awaiting development of an acceptable design, permitting, agreement on costs, and finalization and approval of the construction contract. County has already agreed to contribute $33,000 to the project. The 3/31/2022 deadline recognizes the extent of effort required to finalize a contract, obtain Commission approval, and then complete the work. ACAD is currently awaiting cost submittals for contract Exhibits from Pets Broward.

9

Management work with appropriate County agencies to develop and implement a plan to improve the drainage of exterior areas in order to make them useable for critical enrichment activities.

3/31/2022

To the extent designed drainage areas can be repurposed for enrichment activities, it will be considered as part of the proposed Pets’ Broward project discussed in 8 above.

10 Management proactively and periodically have water retention ponds treated for mosquitos with increasing frequency during the summer months.

N/A Procedures are in place to aid in the proactive treatment of mosquitos.

11

Recommend management design and implement lighting schedules that support the natural (circadian) rhythms of wakefulness and sleep for sheltered animals as indicated by ASV Guidelines.

N/A

Shelter lights are controlled by a sensor which turns them on when it is overcast and/or at dusk and turns them off when night has completely fallen.

12

Recommend management immediately adjust kennel operations work schedules to, at minimum, 6 a.m. to 7 p.m. to: A. Reduce the number of hours animals are left unattended. B. Facilitate the early removal of animal waste to reduce unpleasant odors upon opening. C. Complete major cleaning processes prior to opening to reduce hazards and provide a pleasant environment to volunteers and the public. D. Allow for early feeding to reduce the amount of animal waste produced during the hours the shelter is open to the public.

N/A

Kennel staff moved to 10 hour/4-day work weeks with work hours from 8:00 a.m. to 6:30 p.m. to address the concerns raised.


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Development

Estimated Date of

Next Update

Comments

# Description A B

13 Recommend management implement a 10-hour workday, 4 days a week for kennel operations staff in order to accomplish the workday recommendation in Recommendation 12 above.

N/A See 12, above.

14

Recommend management open the Shelter to the public 7 days a week in alignment with Miami-Dade and Palm Beach Shelters.

As indicated in 1 above, a new Director of ACAD has been hired and is evaluating all major areas of the Shelter and its programs. The new Director will be working with County Administration on ACAD’s 180-day “reset” plan which will include a review of hours of operation. Reset plan presented to Board on 5/11/21 makes no recommendations for opening the shelter 7-days.

15 Recommend management evaluate and implement procedures to lock kennels and cages while the shelter is open to the public.

N/A Padlocks are installed on all kennels and the requirement captured in ACAD procedures.

16

Recommend management assign staff to each kennel area to: i. Monitor visitor and volunteer activities; ii. Ensure the public’s and animal safety while the shelter is open to the public; iii. Perform spot cleaning of animal cages; and, iv. Provide volunteer and customer service assistance. At least one kennel operations staff should always be in each Kennel section during opening hours.

N/A

Staff has been assigned accordingly.

17 Recommend management restrict the removal of animals from the kennels to employees only. N/A

All staff have been informed of the requirement that only staff remove animals from kennels. Procedures have been revised to include this restriction.

18 Recommend management immediately repair and/or enhance the SMT system so that it works as intended. N/A

System has been repaired and is working.


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Development

Estimated Date of

Next Update

Comments

# Description A B

19

Recommend management document disease transmission control procedures for kennel operations and ensure periodic training is conducted for all shelter staff and volunteers to ensure: A. Adequate hand sanitization. B. Appropriate use of protective garments C. Adequate sanitization of equipment

N/A

Kennel staff have been retrained on proper disinfection protocols, including proper usage of protective garments and sanitation equipment. Various procedures have already been updated to address these areas. In addition, a new unifying, single Disease Transmission Control procedure has been developed.

20

Recommend management enhance behavioral health practices and protocols to align with national standards as indicated in A above. N/A

ACAD has worked on simplifying and standardizing behavioral notes modeled after Hillsborough County Animal Care. ACAD staff now notate behaviors in Chameleon, the shelter’s database system.

21

Recommend management ensure all dogs receive a behavior evaluation as required by policy and ensure behavior evaluations are performed periodically for animals in the shelter over 30 days.

6/30/2021

ACAD has reclassified a position to be used for the behavior specialist and is currently recruiting to fill that position.

22

Recommend management ensure behavior classification for animals are: i. Adequately supported by behavior notes within the animal record. ii. Recorded within the animal record to reflect the behavioral classification on the animal kennel card. iii. Entered into the behavior field rather than the overall memo field.

N/A

Animal behaviors are being recorded in behavior notes. Behavioral classifications are designated by a color dot system. Procedures have been developed to explain these measures.

23

Recommend management ensure appropriate procedures are in place and are consistently followed to disclose known behavioral or medical conditions to the public prior to releasing the animal into their custody

N/A

Procedures including reviewing behavior notes with the potential adopter have been implemented.


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Development

Estimated Date of

Next Update

Comments

# Description A B

24

Recommend management develop and implement a formal enrichment program to maintain the health and well-being of animals that includes the types of animals eligible to participate, the frequency of the activity and documentation required to track the performance of the activity. Staffing recommendations in Opportunity for Improvement #1 contemplate the use of additional kennel operations staff for enrichment

N/A

A system to track daily playgroups and dog walking and enrichment procedures has been implemented.

25

Recommend management ensure the volunteer program provides a sufficient number of volunteers to meet the shelter’s needs 8/1/2021

Demand for volunteers has been substantially reduced during construction closure. ACAD's goal is to on-board and train volunteers during closure to ensure an adequate number of volunteers upon shelter reopening.

26

Recommend management evaluate and implement improvements to the volunteer program by addressing the concerns noted by volunteers 8/12/2021

While waiting to fill the Volunteer Coordinator position, the volunteer duties have been assigned to a staff team, which will review volunteer concerns and address as appropriate.

27

Recommend management perform volunteer surveys at various stages of the program as required by the approved Volunteer Standard Operating Procedure 8/12/2021

While waiting to fill the Volunteer Coordinator position, the volunteer duties are being assigned to a staff team, which will ensure surveys are created and issued in accordance with the Volunteer Program SOP.

28

Recommend management outsource the management of pet registration tags using forever tags or implement methods to improve compliance with County ordinances that govern the annual renewal of pet registration tags 6/30/2021

ACAD has conducted an outsource assessment as requested at the 1/26/2021 Commission Meeting (Item 47) and provided that assessment to the Board on 3/12/21. A Request for Information was published and responses reviewed. ACAD is now undergoing a review by Broward County's innovation team for possible in-house solutions.


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Development

Estimated Date of

Next Update

Comments

# Description A B

29

Recommend management implement formal training standards for employees and volunteers that is periodically refreshed on the following topics: ▪Disease recognition; ▪Shelter sanitation; ▪Animal behavior; ▪Safe and humane animal handling; ▪Proper use of equipment; ▪Pet first aid; ▪Disaster planning and response

6/30/2021

All kennel staff have been retrained on proper disinfection protocols, including proper usage of protective garments and sanitation equipment. In addition, many ACAD staff have been certified by the Fear Free Sheltering program. Procedures are being developed for standard training requirements covering each of the items listed.

30

Recommend management implement recordkeeping supervisory and monitoring controls, such as, supervisory reviews and approvals, and periodic checks of electronic and paper records for accuracy and completeness.

6/30/2021

Procedures establishing controls for data quality review and data entry into Chameleon (the shelter database system) have been implemented. Additional procedures will be created to address the additional recordkeeping, supervisory, and monitoring controls.

31 Recommend management design and implement standard inventory control systems and practices throughout the shelter.

12/31/2021 ACAD will review potential systems, including any systems currently being used in the County, for possible implementation.

32

Recommend management: A. Reinforce training on State statute requirements restricting the administration of rabies vaccinations to licensed veterinarians.

N/A

This issue was addressed with the then Director and applicable staff are clear on state statute requirements.

33

Recommend management increase the number of parking spaces at the shelter. In the interim, management should consider using the boat ramp parking lot currently under construction adjacent to the shelter for overflow public parking

12/31/2022

In discussion with Parks, ACAD has a commitment to use a portion of the Boaters Park new parking area for overflow staff parking until such time as Parks' customer demand prohibits ACAD's continued use. To implement, construction of an ADA compatible sidewalk must be completed connecting the parking lot to ACAD. Request for cost estimate submitted to Construction Management.


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Development

Estimated Date of

Next Update

Comments

# Description A B

34

Recommend management phase out the use of smaller cages for cat housing that do not provide a minimum separation of two feet between food, litter and rest areas as recommended by ASV Guidelines.

N/A

To resolve this issue, ACAD has installed cat portals connecting 118 cages.

35

Recommend management ensure that bed and bedding restrictions for animals are adequately documented and approved within the Chameleon system N/A

All kennels were equipped with bedding. In rare instances where bedding is not allowed (because of concerns the pet might tear the bedding and swallow portions), notes are entered into Chameleon.

36

Recommend management develop and implement formal animal handling training during the onboarding of employees and volunteers. Refresher training should be conducted at least annually or when animal handling standards or procedures are updated

N/A

Management developed animal handling procedures and an animal handling handbook. New staff are provided the procedures and handbook and are shadowed by senior kennel staff until skilled in animal handling.

37

Recommend management ensure adequate equipment is consistently provided to employees and volunteers in order to safely handle animals N/A

Every staff member is provided with a slip leash as part of their uniform. For volunteers, leashes are placed in the volunteers’ room and replacements are available at the front desk. Extra supplies are maintained onsite and are available through the kennel supervisors.

38 Recommend management implement an inventory management system to efficiently and effectively track donated and purchased food items


39 Recommend management establish rodent and pest control policies and procedures N/A

ACAD has contracted with third party contractors to provide pest control on a monthly basis.

40 Recommend management establish food handling, preparation and distribution policies and procedures N/A

Procedures established.

41

Recommend management ensure that cleaning supplies are adequately labelled and that a consistent process is established to ensure that volunteers are adequately trained on appropriate use of chemicals and cleaning procedures

N/A

Cleaning supplies have been labelled with the appropriate content and cleaning procedures developed. New safety committee established and assigned this responsibility.


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Development

Estimated Date of

Next Update

Comments

# Description A B

43

Recommend management discontinue the acceptance of owner surrendered animals from outside Broward County or adjust fees for this service to be more commensurate with costs.

12/31/2021

Appropriate code changes will be brought before the Broward County Board of County Commissioners for their consideration.

44

Recommend management perform daily inventory counts [on pets] as required by ACAD’s policies and procedures and ensure appropriate procedures are in place to follow-up on variances and update Chameleon timely

6/30/2021

Procedures will be revisited and will include proper exception follow-up.

45 Recommend management enhance current intake policies and procedures to align with industry guidelines N/A

New intake procedures completed and implemented.

46 Recommend management ensure ACAD’s intake procedures are consistently followed and that animal records are complete and contain all required documentation

N/A Data Quality and intake procedures have been developed and are being implemented.

47

Recommend management implement procedures to ensure that each owner requested euthanasia record is reviewed for accuracy, adequate supporting documentation, and authorization

9/31/2021

Forms and any backup are reviewed and stored electronically. Procedures will be developed to document these efforts.

48 Recommend management ensure that euthanasia approval forms are retained in order to demonstrate that euthanasia approval procedures are followed

N/A Forms are being retained.

49 Recommend management ensure that euthanasia approval forms are uploaded and attached within the animal record in Chameleon.

N/A Procedures completed and implemented.

50 Recommend management document policies and procedures for the completion and approval of euthanasia forms. N/A

Procedures developed for handling of euthanasia forms.

51

Recommend management enhance adoptions policies and procedures to include: i. The post-adoption follow-up and support procedures to minimize the return of animals to the shelter. ii. Checks performed to reduce the likelihood that animals are adopted by individuals with a history of animal abuse and violation of animal control laws.

N/A

i. ACAD currently provides free minor medical care for animals adopted up to 14 days with 2 veterinarian partners. ii. Adoption procedures include Chameleon checks for past issues of concern associated with potential adopters.


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Development

Estimated Date of

Next Update

Comments

# Description A B

52

Recommend management enhance adoptions forms and questionnaires to include inquiries on known pet allergies and the vaccination status of each household pet. N/A

Existing procedures require, through use of Chameleon or other documentation, proof of rabies vaccination/licenses for all currently owned pets. ACAD will not inquire or collect data on potential adopter family health issues.

53 Recommend management ensure adoption application documentation is complete and adequately maintained.

6/30/2021

Management will update all the Training Manuals for Customer Service Representatives to include proper procedures and documentation for Adoption Files.

55 Recommend management ensure animals are posted on the Pet Harbor Website with a photograph. N/A

Management has implemented the new Virtual Shelter, providing pictures and enhanced information to include community access to pet behavior notes.

56 Recommend management review established photograph standards and ensure that they are followed to post acceptable animal photos on its website

6/30/2021 Photograph standards to be developed.

57

Recommend management enhance kennel/cage cards to include animals’ best attributes including temperament and relevant medical information

9/30/2021

Management will work with HLP (the database vendor) to evaluate altering kennel/cage cards to include animals’ best attributes including temperament and minor medical information (i.e., Heartworm Positive, minor skin issues).

58 Recommend management ensure that foster program policies and procedures are formally approved by the Agency Director N/A

Foster program procedures have been updated and approved.


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Development

Estimated Date of

Next Update

Comments

# Description A B

59

Recommend management enhance foster program policies and procedures, considering inclusion of the following elements: Describe requirements for qualifying as a Foster. address the issue of liability for incidents while animals are in the care of Foster. Require home visits. Offer foster family orientations and training upon approval of application. Explicitly encourage fosters to find forever homes for the animals they foster. Review the "Do Not Adopt" list as the agency performs checks of potential fosters for a history of animal cruelty and animal code violations. Procedures for monitoring compliance with clinic visits.

N/A

Foster program procedures have been updated and approved.

60

Recommend management ensure: A. Foster application documentation is complete and adequately maintained B. Foster application documentation is periodically reviewed to ensure continued compliance

6/30/2021

Management will implement data quality procedures to ensure accurate and consistent documentation.

61

Recommend management establish and maintain a formal list of animals requiring foster and track activities to improve, accountability and transparency, utilizing the functionality within Chameleon. N/A

Animals that need foster care are entered in Chameleon and the results displayed in Pet Harbor and ACAD's recently published Virtual Shelter. ACAD has enhanced its process to ensure animals are consistently sent to foster to manage population levels at the shelter and has reflected this enhancement in its procedures.

62 Recommend management ensure that rescue program policies and procedures are formally approved by the Agency Director.

N/A Rescue procedures have been approved.

63 Recommend management ensure that the daily assessments of at-risk animals are performed as required by ACAD’s policies.

N/A ACAD commits to adhering to the applicable ACAD policies.


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Development

Estimated Date of

Next Update

Comments

# Description A B

64

Recommend management ensure: A. Appropriate controls are in place to validate that each rescue partner application is complete and meets minimum eligibility requirements prior to approval. B. Rescue partner eligibility status is reviewed at least annually to ensure continued compliance with minimum eligibility requirements.

N/A

Management agrees to adequately maintain the required documentation for the rescue application files and procedures have been developed accordingly.

65 Recommend management develop and implement formal procedures governing volunteer timekeeping practices N/A

Volunteer procedures have been established.

66

Recommend management ensure evidence to support manual entries and changes to volunteer hours be adequately maintained. In addition, manual entries and changes should be periodically reviewed for accuracy and appropriateness.

N/A


67

Recommend management ensure that appropriate procedures are implemented and enforced to ensure all volunteer hours and activities are entered into the Volgistics system

N/A


68 Recommend management ensure all required volunteer application documentation is complete, executed and retained

N/A Established volunteer application documentation procedures are being implemented.

69 Recommend management document policies and procedures related to pet registration, tag issuance, tag renewals, enforcement processes, and the vet partner program

N/A Policies have been documented.

70

Recommend management ensure appropriate procedures are implemented to: A. Adequately reconcile vet partner registration tags timely. B. Follow up on outstanding remittances and charge interest at 1.25% monthly (fifteen percent (15%) added to the balance due to the County and compounded monthly on the unpaid balances.

N/A

ACAD staff has implemented the following: A. Vet packets are processed within 24 hours and in the order that they were received. ACAD receives 103 monthly vet packets which are processed as quickly as possible. B. Vet partners were contacted and reminded of the following Contract terms: “…on outstanding remittances and charge interest at 1.25% monthly (fifteen percent (15%) added to the balance due to the County and compounded monthly on the unpaid balances”.


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Development

Estimated Date of

Next Update

Comments

# Description A B

71

Recommend management ensure appropriate procedures are implemented to: A. Comply with County policy requiring notices to be sent to veterinarian partners with past due balances at 30, 60, and 90 days after the initial invoices and refer delinquent receivables outstanding 120 days or more to the County Attorney's Office. B. Periodically review veterinarian partner compliance with agreements and take action to evaluate whether the County should continue doing business with the Veterinarian partner.

N/A

ACAD staff has implemented the following: A. Since June 2020, all invoices are sent to vet partners after the reconciliation is completed and each month’s payments are reviewed. If payment is not correct or paid in full, the vet partner is contacted in writing with the past due amount. When necessary, County Attorney’s Office is assisting in collecting the past due sales. B. Vet partner compliance is reviewed monthly and any issues are brought to the attention of the vet partner in writing. Vet partners contacted have been complying with the agreements.

72

Recommend management ensure appropriate procedures are implemented to adequately manage and secure the inventory of pet registration tags.

N/A

The 86 boxes referenced in the Audit have been accounted for. New policies and procedures have been developed to adequately manage and secure the inventory of pet registration tags. A new supervisor is assigned to this Program and new training and new SOPs have been developed. The tags are now locked and secured and controlled exclusively by the manager. Inventory of tags are now counted quarterly, and all tags have a receipt saved and logged into a spreadsheet, as a duplicate recording for confirmation of issuance and accountability.

73 Recommend management provide on-call veterinarian services or contract with a veterinary hospital to provide emergency after-hours care

9/31/2021 Emergency after-hours care services currently being established.

74 Recommend management evaluate and implement methods and resources needed to reduce feline deaths to within industry standards

N/A Feline mortality rates are within industry standards. As of Feb 2020, the local feline mortality rate was about 1% (with industry standard being less than 2%).

75 Recommend management implement an inventory management system to efficiently and effectively track drugs and medical supplies.


76 Recommend management ensure purchasing and inventory management duties are adequately segregated. N/A

Management reallocated staff resources to ensure segregation of duties.


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Development

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Next Update

Comments

# Description A B

77 Recommend management ensure a minimum of one physical inventory count of drugs and medical supplies is performed annually

12/31/2021 A physical inventory of controlled drugs is conducted weekly. An annual medical supply inventory will be implemented by the end of 2021.

78

Recommend management perform monthly medical evaluations for animals in the shelter over 30 days.

N/A

A medical follow-up report has been developed and will be used to identify animals that are past due for medical evaluations and animals who are becoming due within the next week.

79 Recommend management ensure appropriate procedures are in place to validate the completeness of animal records. N/A

Procedures completed and implemented.

80 Recommend management establish a process to ensure that the dosage amount of controlled substances entered into the Chameleon system is accurate and reasonable.


81

Recommend management: A. Ensure rabies clinics are adequately staffed to manage and control the event. B. Implement procedures to manage crowd size, such as appointment times and windows for faster service.

9/30/2021

Existing procedures will be revised and implemented.

82 Recommend management document and approve disease outbreak response procedures N/A

Procedures have been developed.

83 Recommend management implement procedures to independently weigh biohazardous waste to detect billing errors and inaccuracies

N/A Procedures have been developed and implemented.

84 Recommend management identify and contract with a secondary biomedical waste transporter using the county’s procurement process

12/31/2021 Recommendation will be further evaluated.

85 Recommend management ensure established biomedical waste disposal procedures are periodically reinforced and followed

N/A ACAD Clinic staff have been retrained in proper biomedical waste disposal procedures.

86 Management ensure clinic medical facilities and holding areas are frequently and adequately sanitized according to ACAD’s procedures.

N/A Procedures have been developed and implemented.


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Development

Estimated Date of

Next Update

Comments

# Description A B

87

Recommend management ensure actual response times comply with expected response times. Exceptions should be documented and reviewed for reasonableness.

12/31/2021

GPS tracking has been installed in all field vehicles. Procedures will be developed to ensure actual response times comply with expected response times. Any exceptions will be required to be documented and reviewed for reasonableness.

88 Recommend management separate dispatch and call response functions. N/A

Current staffing would not support creating a separate dispatch group. The dispatch function will continue to be performed by the Call Center and ACAD field officers.

89

Recommend management design and implement formal procedures to monitor field service officer activity.

6/30/2021

Procedures have been created to establish formal procedures to monitor field service activity for response time and accuracy. Field officer expectations and QA/QC for field procedures, including GPS data review, are currently being developed.

90 Recommend management routinely monitor field service officer activity for compliance and reasonableness. 6/30/2021

See Response 89.

91 Recommend management ensure all field service trucks are equipped with GPS units. N/A

Implemented. Vehicles in the Animal Care Fleet are now equipped with GPS units.

92 Recommend management implement appropriate procedures to ensure that [controlled substances] data entered into Chameleon matches the logbook entries.

N/A Procedures were revised to ensure correct entry of drug usage in Chameleon and quarterly audits of logbooks/drug usage.

93 Recommend management ensure reconciliation procedures are adequate to consistently identify and resolve errors in controlled substance use logs.

N/A See Response 92.

94 Recommend management ensure procedures to document the reconciliation of controlled substance logs are documented.

N/A See Response 92.

95

Recommend management ensure data entry on the treatment and kennel screens, used to identify who administered a controlled substance, is consistently and accurately input, monitored, and reviewed.

N/A

Staff now has access to a data entry report and are finalizing the report format.


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Development

Estimated Date of

Next Update

Comments

# Description A B

96 Recommend management review and update telephone voice prompts to reduce the number of non-relevant calls transferred to Field Service Officers.

N/A Voice mail prompts have been updated to clarify role of field staff.

97

Recommend management ensure appropriate procedures are implemented to respond to public records requests within a reasonable timeframe. N/A

A new Public Record Custodian has been assigned to handle the Public Record Requests (PRR) and the Division adheres to County PPR guidelines. New Virtual Shelter and Public Dashboard published to increase availability of information online.

98 Recommend management monitor employees to ensure they comply with County policy and ensure employees attend required County training.


99 Recommend management ensure staff receive ACAD specific customer service training as well as periodic refresher training.

N/A Procedures specific to Customer Staff have been developed and implemented.

100

Recommend management ensure adequate coverage of designated Customer Service phone lines.

N/A

ACAD will continue phone coverage with its existing strategy (primary reliance on the call center, secondary reliance on ACAD staff), but will monitor call activity and adjust phone messaging as required to reduce unanswered calls at ACAD.

101

Recommend management review policies, procedures, and training related to handling of calls coming into the shelter and provide an option to speak with someone at all times since some members of the public may not have access to the internet to access information.

6/30/2021

Management will review policies, procedures, and training related to handling of calls coming into the shelter. See also response 100.

102

Recommend management conduct periodic surveys of visitors to the shelter as well as groups that interact with the shelter to gather opportunities and recommendations for improvement to shelter operations.

N/A

Customer and Rescue program surveys have been created and implemented. ACAD also tracks and responds to Google Survey responses.

103 Recommend management review the comments collected above and evaluate whether any comments noted above not specifically addressed in this report can be resolved.

N/A Management reviews comments received and responds as appropriate.


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Development

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Next Update

Comments

# Description A B

104 Recommend management work with the Board of County Commissioners to appoint the required members of the Animal Care Advisory Committee.

6/30/2022 Currently four vacancies remain. Advisory Committee talking points for candidates being provided to Commissioners.

105 Recommend management work ACAC to restrict agenda items to functions and responsibilities outlined in the Code of Ordinances.

N/A The ACAD Director will work with the ACAC at all future meetings to restrict agenda items to functions and responsibilities outlined in the Code of Ordinances.

106 Recommend management ensure partnerships with third party organizations are controlled by written agreement

6/30/2022

Procedures will be developed to ensure such partnerships are controlled and consistent with all County requirements.

107

Recommend management goals improve the alignment between organizational objectives and performance measures.

3/31/2022

The Performance Measures (PMs) will be reevaluated to reflect ACAD's focus on the four pillars of shelter maintenance, equitable service provision, public safety, and community animal care and finalized during the FY 2023 Budget Process.

108 Recommend management ensure the agency’s performance measures are adequately supported. N/A

Agency performance measures are adequately supported by an administrative staff person.

110

Recommend management evaluate organizational reporting relationships and implement a supervisory structure to reduce the number of individuals that report directly to the Assistant Director. Each supervisor would then have direct reports reducing the Assistant Director’s span of control.

N/A

Span of control has been distributed between the Interim Assistant Director, Business Manager, and Assistant to the Director. Appropriate span of control will be maintained as ACAD transitions to new leadership.

111

Recommend management ensure emergency evacuation procedures are adequate and are periodically reinforced through practice drills

9/30/2021

Management conducted a practice drill in FY 20. Management will ensure emergency evacuation procedures include periodic drills and that those drills are conducted.

112

Recommend management develop or update policies and procedures related to the SNIP, TNR, and RTF programs. Once developed, policies and procedure should be reviewed and approved by management.

N/A

Procedures have been developed for SNIP, RTF and TNR.

113 Recommend management perform income validation procedures or revise voucher eligibility requirements. 12/31/2021

Management will review the current process and evaluate potential alternatives.


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Development

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Comments

# Description A B

114 Recommend management enhance voucher redemption procedures to prevent the payment of duplicate, expired, and invalid vouchers

12/31/2021 See Response 113

115 Recommend management update procedures to require veterinarians to validate vouchers are accepted for eligible animals only.

12/31/2021 See Response 113

116

a. Recommend management develop and implement methods to assess the effectiveness of the program [Spay and Neuter]. b. Recommend management ensure animal data classifications are in compliance with County ordinance.

3/31/2022

a. Management will develop effectiveness monitoring strategies for the spay and neuter programs. b. Management follows standards recognized by the animal welfare industry for classifying animals that are admitted under returned-to-field (RTF) and sheltered-neutered-return (SNR) programs. Management will seek amendment of the Broward County Ordinance to align with industry standards.

117 Recommend management establish goals for the number of adoption events and the number of animals adopted through these events, and track progress towards achieving them.

9/30/2021 Management to improve this process for tracking purposes and establish adoption event goals.

118 Recommend management implement surveys or other methods to independently track and measure the effectiveness of promotional activities.

9/30/2021 Management will implement surveys or other methods to independently track and measure the effectiveness of promotional activities.

119

Recommend management: A. Ensure that employees are required to clock-in/out and manual entries are kept to a minimum based on exceptions. B. Implement procedures to periodically review manual time entries made by Supervisors for reasonableness.

N/A

Procedures on timekeeping process have been developed and implemented.

120

Recommend management ensure: A. Each trust fund is setup and managed independently. B. Recognize revenue, including accounts receivables in the period in which it is earned. C. Donations are recorded accurately in the correct account. D. Fund disbursements are compliant with the Code of Ordinances.

N/A

The Trust Funds have been setup and independent management oversight has been assigned. Management will continue to ensure revenues and accounts receivable are properly recognized. A review process has been implemented and donations are recorded accurately in the correct account. Fund disbursements are compliant with the Code of Ordinances.


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Development

Estimated Date of

Next Update

Comments

# Description A B

121 Recommend management establish written policies and procedures for citations. 9/30/2021

Policies and procedures will be developed and implemented.

122 Recommend management revise the citation form to include the disclosures as required per the Broward County Ordinance.

9/30/2021 Management will revise the citation form to include the disclosures as required per the Broward County Ordinance.

123 Recommend management enhance current mail processing procedures to require two employees to open and process mail.

N/A Dual control procedures have been included for opening and processing mail.

124

Safe Combinations are not changed periodically to prevent unauthorized access.

N/A

Policies and procedures have been revised to change safe combinations at the end of each fiscal year and when employees with access no longer require access to the code.

125

Recommend management ensure: A. Cashier Certification Forms are reviewed and approved by supervisory personnel. B. Cash receipts are deposited the next business day. C. Cash overages and shortages are documented, tracked, and reviewed.

N/A

The cash handling and mail procedures have been updated and implemented accordingly.

126 Recommend management work with the County Attorney’s office to update and renew the contract with Pet Supermarket.

3/31/2022 ACAD will work with the County Attorney's Office and Pet Supermarket to renew these contracts.


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Development

Estimated Date of

Next Update

Comments

# Description A B

127

Recommend management ensure: A. Cardholders comply with the County’s P-Card policies. B. Purchased for amounts in excess of the P-Card limit are competitively procured.

N/A

A. All P-Card holders will be required to repeat the annual P-Card training by Purchasing. Internally, ACAD Management has held onsite P-Card training to all card holders as refresher. B. Purchases made in excess of the P-Card limit have obtained prior approval from Purchasing each time. Competitive procurements through Purchasing have occurred with several purchases between 2018 and 2020. Consistent with Purchasing policies, P-Card holders have obtained at least two competitive quotes for all purchases under $3,500 and three formal quotes have been obtained for all CAB POs for competitive procurement.

128

Recommend management ensure: A. Master Agreements are utilized when available. B. Management establish master agreements for food and supplies frequently purchased.

12/31/2021

Master Agreements are and have been utilized when available. The County has established the Incident Response System (IRS) for procurement of PPE and per Purchasing’s guidelines ACAD is accessing all PPE via IRS. ACAD is evaluating the best fit procurement methodology for food and frequently purchased supplies.

129

Recommend management ensure the agency complies with the County’s procurement policies: A. Obtaining the required number of quotes based on the purchase price. B. Having the receiver sign the accompanying invoice or receiver slip. C. Tagging and capitalizing purchase greater than $1,000.

N/A

ACAD is complying with these procurement policies, noting the new tagging limit is now $5,000.

130 Recommend management ensure that all access changes are consistent with the access authorized on a user access request form.

N/A Identified access errors were corrected and procedures reflect the requirement for consistency between access changes and authorized access.

131 Chameleon Minimum Password Requirements do not Comply with County Policy. N/A

Password requirements now comply with County Policy.

132 Monitoring of Developer/Administrator Access to Production Environment Requires Enhancement. 12/31/2021

Management will work with ACAD's IT support to derive a feasible monitoring solution.


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Development

Estimated Date of

Next Update

Comments

# Description A B

133

Recommend management ensure the use of generic accounts is restricted, where possible. In instances when these accounts must be used, management should ensure appropriate controls are in place to monitor user activity and tie that activity to authorized individuals.

N/A

Generic accounts are read only access. The Volgistics administrator account, which permits system changes, is linked to the Volunteer Coordinator email address.

134 Recommend management configure the available password security parameters to meet or exceed County policy. N/A

User accounts have been updated to comply with the County's password policy.

135

Recommend management ensure volunteer activities in Volgistics agree to job preference options included in application documents to facilitate appropriate volunteer assignment, tracking, and data analysis.

N/A

Volgistic job preferences have been modified to match volunteer activities on the volunteer application.

Notes

1There are no Recommendations 42, 54 or 109

Prepared by: Jeffery Halsey ([email protected]), Assistant to the ACAD Director

ACAD Audit Checklist

Documents

Transcript of ACAD Audit Checklist