FTA Drug and Alcohol ProgramNATIONAL CONFERENCE

You’re Being Audited by FTA

-What Should You

Expect?

Lori DeCoste & Ed VanderPloeg

Session Goals• Discuss the FTA audit process, from initial

notification through issuance of the compliance letter

• Give grantees a better understanding of what to expect when they get "The Call"

Background

• FTA audits approximately 45 grantees and states each yearAn audit team is in the field 24 weeks out of each yearRotating cast of auditors, Audit Team Leaders, and federal representativesSelection for audits based on several criteria – not just “red flags”

• Process is largely identical no matter who we audit, who is on the audit team, or who is leading the audit

• Grantees with multiple contractors and State DOTs are scheduled somewhat differently, but what we look for is the same everywhere

Background

• FTA views the audit primarily as:An opportunity to assess selected grantees’ level of complianceA chance to offer specific guidance on potential corrective actionsAn effective way to enhance public safety

• However, it is also a non-confrontational learning experience to help develop your best possible D&A program (please believe us!)

• FTA, grantees, contractors, and vendors have the same goal: protect public safety through compliant D&A programs

Phases of the Audit Process

• There are three distinct phases to the audit process:1. Notification/Pre-Audit2. Site Visit3. Post-Audit/Compliance

• We will discuss each phase in turn

Pre-Audit

• Seven (7) weeks prior to the scheduled audit, the DAPM of the selected grantee will get a phone call from the Audit Team Leader

Notification that they have been selected for an auditSelected dates are firm once agreed uponBasic overview of audit process and information needsOverview of schedule/deadlines for the next seven weeksIdentification of contractors/sub-recipients (as applicable)Try to put the DAPM at ease – although this rarely works!

Pre-Audit

• Within a few days of initial conversation, Team Leader issues formal notification letter via email (sometimes the same day)

• Letter includes a draft agenda for the audit and list of information required from the DAPM (both pre-audit and during audit)

• After DAPM has had a day or two to absorb the letter, Team Leader makes follow-up phone call to answer any questions

Pre-Audit

• As soon as possible after notification, DAPM will:Notify key individuals within the organization of the auditNotify contractors and vendors of the auditShare notification letter as neededBegin gathering the pre-audit information package (due 3 weeks from

initial call)

• Careful preparation at this stage helps ensure a smooth onsite experience

• Three (3) weeks after the call, the following materials are due to Team Leader and FTA – from grantee and contractor(s), as applicable

1. Current Substance Abuse Policy2. Encrypted/protected spreadsheets with previous twelve (12) months of

testing data (pre-employment, random, post-accident)3. Lists of employees (if any) tested for reasonable suspicion, return-to-duty,

follow-up4. Contact information for MRO and SAP5. Completed schedule with addresses and contact information for grantee,

contractors, collection site6. Other materials specifically identified in notification letter

Pre-Audit

• After receiving the pre-audit package at the three (3) week point, the Team Leader completes several tasks during Weeks 4-6

1. Determines whether the package is complete; obtains any missing pieces2. Reviews policy for compliance; writes up any deficiencies

Typical findings: Missing elements, list of refusals incomplete, incomplete/incorrect descriptions of DOT/FTA requirements

3. Analyzes testing data and enters into auditing software (“SAMO”)

Pre-Audit

• Team Leader tasks during Weeks 4-6 (cont.)4. Determines whether SAP and MRO have been interviewed recently. If not,

DAPM will schedule dates/times for phone interviews by Team LeaderSAP interview: 20+ questions / 15-20 minutesMRO interview: 60+ questions / 30-45 minutesUsually conducted 1-3 weeks prior to onsite auditTypical findings: Unaware of certain elements of 49 CFR Part 40

Pre-Audit

• During the entire pre-audit phase, Team Leader and DAPM are in frequent phone/email contact

Discuss questions and request/find supplemental information

• Weeks 4-5 after notification are generally low-effort for the DAPM

Pre-Audit

• During Week 5 or 6, Team Leader provides DAPM with final audit schedule and lists of records selected for onsite review

DAPM distributes schedule to all interested parties, including contractors/sub-recipients

DAPM needs to “pull” all of the required records from the files prior to the audit team’s arrival

Contractors also need to pull records in advance

Pre-Audit

• During Week 6, Team Leader speaks with DAPM one last time to ensure s/he is prepared for the audit and that there are no outstanding questions

• Audit team travels to the relevant location and we move to the onsite phase of the audit

Pre-Audit

Site Visit

• Audit team arrives at the grantee location

• Entrance interview begins – usually either 9 AM or 1 PM1. Introductions2. Overview of audit process/schedule3. Questions/answers about process4. Invitation for staff to be present during all phases of the audit (“open

process”) including collection site visit and contractor audit (if applicable)

• Records review begins

Site VisitRecords Review – Pre-Employment

What we look for:• Verified negative test result prior to

placement into safety-sensitive (SS) duty• No more than 90 days elapse between

negative result and first performance of SS duty• Previous employer records requests

Site VisitRecords Review – Pre-Employment

Typical findings:• Employees placed in SS duty before a

negative result is received• No test result at all

Site VisitRecords Review – Random

What we look for:• Unpredictable spread of random testing

Throughout the yearDays of the week Hours of the day

• Valid and recorded excusals

Site VisitRecords Review – Random

Typical findings:• Lack of weekend testing• Lack of early morning/late night

testing• Excusals for invalid reasons, or

not fully documented

Site VisitRecords Review – Post-Accident

What we look for:• Accident meets FTA criteria• Decision-making process documented• Time limits: 2hr/8hr/32hr rules

Site VisitRecords Review – Post-Accident

Typical findings:• FTA tests after incidents that do not meet testing criteria• FTA tests conducted after employee is clearly discounted as a

contributing factor to the accident• Delays in alcohol testing not documented• Decision not to perform FTA test (after thresholds are met) insufficiently

documented

Site Visit

Records Review – Reasonable Suspicion

What we look for:• Determination based on specific, contemporaneous, articulable

observations (well-documented)• Ordered by trained supervisor (2 hour training)• Time limits: 2hr/8hr rule

Typical finding:• Testing based on observations that do not meet FTA criteria

Site VisitRecords Review – Return-to-Duty/Follow-Up

What we look for:• Written evaluations and follow-up testing plan from SAP that meet Part 40

requirements• Negative return-to-duty test prior to returning to SS duty• Follow up tests according to the SAP’s testing plan• All tests under direct observation

Typical finding:• Testing does not follow SAP’s testing plan

Site VisitRecords Review – Miscellaneous

What we look for:• Proper completion of CCFs and ATFs at the collection site

Are CCFs/ATFs reviewed for errors and corrected as needed?

• Records maintained in a secure location• Required drug training for all covered employees• SAP referral provided to anyone who fails or refuses a DOT test

Site VisitRecords Management Interview• Less of a formal “interview” than a reporting of what was observed during

records review

• Sometimes supplemental records may be requested:Employee/supervisor training recordsRandom testing selection listsForms used to document various aspects of the programDocumentation of policy receipt by employees

Typical findings:• Missing records

• Inadequate/non-compliant forms

Site VisitDAPM Interview• Federal representative interviews the DAPM• Questions assess DAPM’s knowledge of the regulations and procedures for

conducting required D&A testing• Sometimes more than one person is interviewed (i.e., assistant/backup)• 80+ questions / roughly 1 hour

Typical findings:• DAPM unaware of certain regulatory requirements• No vendor/contractor oversight

Site VisitCollection Site Visit• Part of the team splits off to visit the primary collection site

DAPM sometimes attends to witness how we audit the collection site

• Mock drug and alcohol test – one auditor is the “donor” while another observes BAT/collector• Follow-up questions assess BAT/collector knowledge of the regulations and

procedures for dealing with unusual circumstances BAT: 60+ questions / roughly ½ hour Collector: 80+ questions / roughly 1 hour

• Review calibration records, training certificates, QAP

Site Visit

• Urine Collector: Steps completed out of order Unaware of how to deal with non-

routine collections (i.e., employee is uncooperative)

Inadequate shy bladder procedures

• BAT: Failure to conduct alcohol test

first Unaware of BAC that is

considered a violation Unaware of issues that result in

cancelled test

Collection Site Visit

Typical findings:

Site VisitWrap-Up/Debriefing• When all interviews and record reviews are completed the auditors provide a

verbal debriefing of any deficiencies and the required corrective action Our goal: “No surprises” in the audit report Chance to discuss issues further if desired

• Depart for day – write report in hotel• If no contractors, final audit report generally delivered the next morning

Site VisitContractor Site Visits• If there are contractors to be audited, auditors visit them the following day(s) and

follow the same audit process outlined aboveGrantee is fully responsible for compliance of its contractorsGrantee should not assume contractors have full knowledge of the requirements or that

their policies/programs are compliantDAPM often attends contractor site visits

• Final audit report typically delivered to grantee the morning after the final contractor audit

Site Visit

Exit Interview• Presentation of final audit report• Exceptions report – only lists deficiencies that require action• Discuss format of the report and some highlights – not every finding• Describe the response process

Formal response due 90 days after exit interviewAudit response software – only grantee uses (i.e., not contractors or vendors)Back-up documentation required as noted in report

• Answer questions• Duration: anywhere from 15 minutes to 1 hour• Audit team departs

Post-AuditAudit Response• Policy modified (as applicable), provided to Team Leader for review prior to 90-

day deadlineOnce “blessed” by Team Leader, policy may be approved/distributed to employees

• Testing procedures modified as needed, and documentation provided • Forms and documents developed/modified as needed and copies provided• Statements of regulatory understanding written and provided• Contractor and vendor (i.e., collection site, SAP/MRO) responses coordinated

by grantee DAPM• All responses entered into response software; file provided to Team Leader• DAPM has access to Team Leader throughout response period

Post-AuditReview of Audit Response• Response received by Team Leader no more than 90 days after the date of

the final audit report• Reviewed by Team Leader for completeness and adequacy• If incomplete or inadequate, further action required

“Minor” or “quick” fixes – grantee may be provided a limited amount of time to provide a supplemental response (e.g., forgotten items/documentation)

More serious issues will result in a formal Continuing Concerns Report and another defined response period (e.g., 45 days, 60 days) depending on the nature of the issues

• If all responses are complete/adequate, Team Leader issues compliance letter• Compliance letter formally closes out the audit – you’re done at last!

Ongoing Support

• FTA is a resource to which DAPMs have ongoing access

• Do not hesitate to contact with questions as they arise Are these proposed policy changes compliant?

Is this an acceptable spread for random testing?

I am conducting training – are these materials adequate?

FTA Drug and Alcohol Program Hotline: (617) 494-6336 or fta.damis@dot.gov

Questions?

Ed and Lori are available to answer your questions after this session – please come say hello!

FTA Drug and Alcohol ProgramNATIONAL CONFERENCE

THANK YOU

Atlanta, GA 2015