Title
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?
• 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 (Preemployment, 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
www.mvtransit.com
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
www.mvtransit.com
www.mvtransit.com
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
1. 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)
2. 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)
3. 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 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
www.mvtransit.com
Preparing Re
Preparing 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:
1 Testing notification form
2 Employer copy (Copy 4) of the custody and control form (CCF)
3 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
•
•
•
•
•
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.
www.mvtransit.com
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.
www.mvtransit.com
www.mvtransit.com
www.mvtransit.com
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.
Auditor Requires
Goal & Attempt in
Audit Response
Majority of week
adequate
www.mvtransit.com
www.mvtransit.com
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 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 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.
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
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 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)
Title
Thank You!
Part 40 Workshop
Denver, Co
May 13th and 14th 2014
By Esther Avalos, Director of Compliance