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Title. What to Expect in an Audit and How to Prepare for It. Part 40 Workshop Denver, Co May 13 th and 14 th 2014 . By Esther Avalos, Director of Compliance. Where do I start?. Start by printing Attachment B, requested items

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What to Expect in an Audit and How to Prepare for It

  • Part 40 Workshop
  • Denver, Co
  • May 13th and 14th 2014

By Esther Avalos, Director of Compliance

where do i start
Where do I start?
  • Start by printing Attachment B, requested items
  • Print the “Attachment A” that pertains to your audit schedule.
  • Print a “Summary Report” of your DOT drug and alcohol records for the audit time frame
  • Organize your testing records by test type (Pre-employment, random, post accident, reasonable suspicion, etc.) and then by date of collection (DOT TESTS ONLY)
  • Print out a summary report of all safety sensitive new hires for the audit time frame.

Where do I start?

  • Contact your Vendors immediately – MRO , SAP, and Collection Site, let them know they will be interviewed and the clinic will be physically reviewed
  • Require them to send you all of their most current certifications (make sure they are not expired)
  • Send them the FTA questionnaires so they can become familiar with the questions and correct answers and ensure they are ready for the interviews.
  • Set up a meeting with the clinic to view their processes and ensure they are compliant with Part 40 collection requirements

What are the Auditors Looking for?

  • Knowledgeable DAPM/DER
  • Compliant Policy
  • Valid testing processes
  • All applicable training & record keeping
  • Info and qualifications of Vendors
  • MIS reports, Semi-Annual reports

Key Elements and Helpful Tools

  • Policies and documentation of dissemination to all covered employees
  • 2 Year Previous Employer Background Check Consent form
  • Training materials for the training of safety-sensitive employees and supervisors
  • Testing Notification Form (aka Notice to Test)
  • Random testing spreadsheets and graphs
  • Post Accident Testing Decision Tree and Documentation form
  • Reasonable Suspicion Testing Determination form
  • Collection Site Visit forms/ mock collections
  • Testing Statistical Reports
preparing re
Preparing Re

Policy and Availability to Employees

  • Documentation that all covered employees have received the current substance abuse policy- Best practice is to have employee sign an acknowledgement of receipt statement
  • Notice of Availability is a sign or posting that the policy is available to employees- Tip you can incorporate this with the Drug Free Work Place Posting
  • Display and distribution material (should be hanging in common areas) EAP Program, helpful information on substance abuse
  • Note: If you conduct NON DOT testing under your own authority, make sure that EVERYTHING related to that testing is clearly defined in your policy and on your forms

NOTE: Posting a policy on your agency website or internal “bulletin” board does not constitute distribution of the policy to all covered employees

preparing re education and training
Preparing ReEducation and Training
  • FTA requires that each employer shall display and distribute informational material and a community service hot-line telephone number for employee assistance, if available (49 CFR Part 655.14a)
  • FTA requires that a minimum of sixty (60) minutes of training be provided to all covered employees on effects and consequences of prohibited drug use on personal health, safety and the work environment. (49 CFR Part 655.14b)
  • FTA requires that “supervisors” or other company designated officials receive a minimum of sixty (60) minutes of training on the probable signs and symptoms of prohibited drug use AND a minimum of sixty (60) minutes of training on the probable signs and symptoms of alcohol misuse prior to making reasonable suspicion testing referrals. (49 CFR Part 655.14b)
preparing re1
Preparing Re

Hiring Safety Sensitive Employees

  • Ensure that you have a pre-employment, MRO verified NEGATIVE result for all persons hired.
  • Ensure that the date of each employee’s first performance of safety-sensitive duties was AFTER the date that you received the negative result. (Note, auditors will look at the date the MRO reported the test and compare that to the date the employee first performed his/her safety sensitive function- this includes behind the wheel training)
  • Make sure that you have a completed drug and alcohol background check (40.25) for all new hires that held previous DOT jobs.

-If you don’t have the completed background check, be prepared to show documentation of good faith efforts to obtain it.

  • Make sure employee received policy and signed acknowledgement
preparing re preparing records for review
Preparing RePreparing Records for Review
  • Create a binder or expandable file folder specific to the records to be audited (example- May 1, 2013 to May 31, 2014)
  • Using the summary report, check to see that you have a record for each test identified on your report. (DOT TESTS ONLY)
  • Show the testing paper trail for each result:
    • Testing notification form
    • Employer copy (Copy 4) of the custody and control form (CCF)
    • Signed (electronic ok) MRO certificate of Negative Results (or a separate copy of the MRO signed CCF)
    • If an alcohol test was also conducted, attach that as well
    • If it was a post accident test, attach the completed Post Accident Decision and Documentation form
    • If it was a reasonable suspicion test, attach the R/S documentation form
preparing re reviewing ccfs atfs notification forms
Preparing ReReviewing CCFs, ATFs, Notification Forms
  • Completeness of the CCF and/or ATF - Steps 1 - 5
  • Accuracy of the CCF/ATF - Time, date, test type, testing authority
  • Timeliness of the collection process - Start-to-finish times and wait times
  • Check your ATF and CCF to determine ensure BAT occurred first
  • Monitor your employee’s allotted time to ensure employee got to clinic on time)
  • Make sure your Notification Form info matches the CCF/ATF (time of collection)
  • Fatal flaws must be corrected by error correction training within 30 days
  • Don’t try to hide anything.
    • If you know of an error you made, own up to it and document it
    • If there are records you are missing, make an affidavit or memorandum of correction “note” and attach it into the file as a place holder.
when employee returns
When Employee Returns

Once employee returns from testing, do the following:

Make sure that this section is filled out. If information is missing, immediately contact the collection site and request written documentation to correct and fill in the missing information.

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Preparing Re

Random Testing Records

In the “Randoms” section of your binder:

  • File the random selection list and each corresponding test behind it (with the paper trail items)
  • Auditors will record the time and date of each random test. They will be determining if you are testing “through all hours of operation”.
  • (If you did not have any change in employees from one quarter to another, make a note of that and insert it into the binder where the update would be.)

Any employee notified for testing (including managers) must submit to testing and immediately proceed to the pre-established collection site (local clinic).Selected employees who are “not available” is limited to employees who are not at work due to vacation, sick leave, disability, or scheduled time off. This does not mean that the employee cannot be tested when they return to work, if the random selection list is still valid the employee must be tested.

Managers should ensure that tests are unannounced and unpredictable and test dates must be spread reasonably throughout the month, week, and time of day. Random testing must be conducted at all times that safety-sensitive duties are being performed. Testing must be spread out over all shifts including weekends and holidays.

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Preparing Re

Post Accident Records

  • Prepare the testing records in the “Post Accident” category the same way as the others (show paper trail)
  • Attach the Post Accident Decision and Documentation Form to the paperwork. make sure any delays in testing are documented
  • Ensure that you have both a drug test result AND an alcohol test result for each event that met the criteria to test
  • If you did not conduct both, OR if you do not have documentation of the incident OR if you feel that the event may not have met the criteria but testing was performed anyway– Document your reasons and include in file.
preparing re4
Preparing Re

Reasonable Suspicion Records

  • File the testing paper trail just as with the other test types
  • Include the determination form and any other supervisor statements, etc. that are pertinent to the decision process
  • Also be prepared to show documentation that the supervisor that “made the call to test” received training in accordance with 655.14(b)
preparing re5
Preparing Re

Return to Duty/Follow Up

  • For Employers that have a Second Chance program
    • Must include initial referral to SAP
    • Must show SAP recommendation letters for return to duty (employee met requirements)
    • Must show that a DIRECTLY OBSERVED collection was conducted for the return to duty test and any follow up tests.
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Preparing Re

How to Monitor Your Vendors

  • COLLECTION SITE – Physically go to your clinic and set up a meeting, review their entire collection processes, document the visit and findings and corrective actions (if needed). Obtain copies of all certificates of training and EBT calibration.
  • MRO- Obtain credentials and copies of certificates and continuing education (every 3 yrs)
  • LAB -Obtain DHHS/SAMHSA certifications (check DOT website to ensure your lab is in good standing)
  • SAP- Obtain certifications and continuing education
  • TPA- Be clear about your expectations taking bids, drafting contracts, operating agreements
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Preparing Re

Collection Site

  • Collection site compliance monitoring is NOT a regulatory requirement, however your collection site’s compliance has a huge baring on your agency’s overall compliance
  • Collection sites are often the weakest link in the program
  • Inspections of your collection site can help you accurately determine the level of compliance to security measures, for example:
    • Bluing agent in toilet bowls?
    • Water sources secured in bathroom?
    • Is the collection area accessible to unauthorized persons?
    • Are there contaminants in the bathroom (soap, cleaning agents, etc.)?
    • Are there receptacles or items that could be used to hide adulterants or substitution aids (trashcans, paper towel holders)?
    • Are the specimen cups accessible to unauthorized persons?
  • Create an after hours testing toolkit for Post Accident and Reasonable Suspicion testing that answers supervisor’s FAQs (Where are the CCF forms? Where do we take the employee? Do we have to call someone?)
preparing re8
Preparing Re

Final Steps for Audit Prep

  • Present only the records and documents that have been requested. Do not bring out ALL of your records. *** Keep NON-DOT records away!
  • The pre-audit documents will set the stage for the actual audit
  • Make sure your files are in a secure and locked area with minimal access and to only designated employer representatives
  • Walk around your building/offices make sure your Drug Free Postings are up and have not been taken down
  • Any errors you find while preparing for your audit should be clearly documented and corrected.
    • For positive results: documentation of a SAP referral being provided to the applicant or employee (EVEN IF YOU ARE ZERO TOLERANCE)

Thank You!

  • Part 40 Workshop
  • Denver, Co
  • May 13th and 14th 2014

By Esther Avalos, Director of Compliance