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?