Office of Risk Management Loss Prevention Unit Manual & Audit Update

HOW WE GOT HERE A BRIEF TIMELINE

TIMELINE July 2004  Directive from State Risk Director to revise current subjective, rating-based audit to an objective, score-based process First major overhaul since 1992  Brainstorming sessions begin Multiple 2-day staff meetings held to review every audit question and section of the manual  Improvements  Additions  Deletions

TIMELINE August-December 2004  Completion of 1 st and 2 nd drafts First time audit and manual are ever cross-referenced January-March 2005  Submitted to Commissioner’s Office for review March 2005  Point person in Commissioner’s Office resigns

TIMELINE March-August 2005  Responsibility of review process shifted Committee formed and review process starts anew Certain components sent within ORM and DOA for input August-December 2005  Katrina and Rita Re-write process slows as Loss Prevention Unit’s focus shifts to recovery/re-alignment efforts

TIMELINE January-May 2006  Review committee completes efforts and submits to new point person in Commissioner’s Office for final sign-off Several rounds of questions and clarification June 2006-Present  Final, approved versions sent to 3 rd party developer for integration into software

WHO WAS INVOLVED ORM  Loss Prevention staff  State Risk Assistant Director and Director  Claims  Medical  Transportation  Underwriting  Workers’ Compensation

WHO WAS INVOLVED DOA  Commissioner’s Office  Fleet Management  Flight Maintenance  Legal  OSRAP

WHAT’S AHEAD Audit vs. Compliance Review (CR)  Full audit once every 3 years 1/3 of agencies/year FY FY FY 07-08FY FY FY CRs CRs 7/1/071/3 Audits (Group 2) 1/3 Audits (Group 3) 1/3 Audits (Group 1) 2/3 CRs (Groups 2, 3)2/3 CRs (Groups 1, 3) 2/3 CRs (Groups 1, 2) 2/3 CRs (Groups 2, 3) 3/07 3/08 (Group 1) Roll Out 1/3 Audits (Group 1) 12 Months

WHAT’S AHEAD  Compliance Review (CR) during other two years  Self-audit required every year, due at the time of the audit or CR Lack thereof will result in failure of the audit/CR  Prior to audit/CR, letter from agency head must be sent confirming readiness Due by 1 st of the month prior to date of audit/CR

WHAT’S AHEAD Automated audit process  Self-audit will be available on STARS server Roll out to agencies as soon as STARS Compliance revisions are complete  LPO will use tablet PC to conduct in-person Point values for questions, not for comments Additional Support  Review trending reports from STARS  Consult with agencies on particular concerns Target areas of high loss to lower claims

Office of Risk Management Loss Prevention Unit Manual & Audit Update

General Safety Audit Components: Program Safety Meeting & Training Inspections Incident/Accident Investigation Recordkeeping Bloodborne Pathogens/First Aid Emergency Preparedness Plan Hazardous Materials

General Safety Audit “Program” Requirements: The written general safety plan should include safety responsibilities for all employees. The written safety responsibilities should:  Be presented to all employees during orientation and/or upon assignment to a new position with different/additional safety responsibilities  Contain a documented method of accountability General and site/task specific safety rules:  Must be distributed to employees during orientation and such action documented

General Safety Audit “Safety Meetings & Training” Requirements: Percentage of employee attendance at safety meetings must be calculated and documented  Minimal acceptable attendance is 75%  Department/Agency head must attend ALL safety meetings

General Safety Audit “Safety Meetings & Training” Requirements: cont. Mandatory training topics:  Drug and substance abuse  Sexual harassment Required within one year of hire and at least every 5 years thereafter

General Safety Audit “Safety Meetings & Training” Requirements: cont. Safety Committee :  Is a committee established  Frequency of meetings should be based on agency class (Class A/Class B)  Attendance and topic of meeting should be documented

General Safety Audit “Safety Meetings & Training” Requirements: cont. If applicable, field safety coordinators should receive training on the following:  Accident investigation  Inspections  Safety meetings  Supervisor responsibilities  Job safety analysis

General Safety Audit “Safety Meetings & Training” Requirements: cont. The agency loss prevention representative must attend the ORM Loss Prevention Program at least once every three years Documented, specific training should be provided to all employees who must perform new tasks or operate new equipment OR whose safety performance is unsatisfactory

General Safety Audit “Inspection” Requirements: Indicate number of potential/actual inspections conducted Percentage of inspections conducted must be calculated and documented Type inspection form used  Departmental  Agency/site specific

General Safety Audit “Inspection” Requirements: cont. Building inspection form should include the following topics:  Building safety  Electrical safety  Emergency equipment  Fire safety  Office safety  Storage methods

General Safety Audit “Inspection” Requirements: cont. Is there a method in place for employees to notify management of workplace hazards?  Hazard Control Log (HCL) or other acceptable means

General Safety Audit “Incident/Accident Investigation” Requirements: Investigation procedures should address the following:  Employee, visitor, and/or client situations (via the DA2000)  Bodily injury and/or property concerns  Use of the Incident/Accident Investigation form (DA2000) Must have designated employee review forms for completeness and accuracy

General Safety Audit “Incident/Accident Investigation” Requirements: cont. Job Safety Analyses (JSA):  Annual documented training required  Review of applicable JSAs in post- incident/accident situations

General Safety Audit “Recordkeeping” Requirements: Records that require, at a minimum, 5 years retention:  Bloodborne pathogens  Drug testing and substance abuse  Sexual harassment

General Safety Audit “Bloodborne Pathogens/First Aid” Requirements: Is the written program departmental or agency/site specific Training guideline for “high-risk” employees:  Within 3 months of hire  At least once per year thereafter Training guideline for “low-risk” employees:  Within 12 months of hire  At least once every 5 years thereafter Are spill procedures in place  Spill kits maintained

General Safety Audit “Bloodborne Pathogens/First Aid” Requirements: cont. Does the agency location meet any of the following criteria:  Working with minimal/partial crew shifts  Employees working in remote/isolated locations  The on-site medical facility is closed If so, does the agency have someone available in these situations who is trained/able to render first aid

General Safety Audit “Emergency Preparedness Plan” Requirements: The written plan must address, at a minimum:  Fire  Natural disaster  Proximity threats  Terrorism

General Safety Audit “Hazardous Materials” Requirements: Is the written program departmental or agency/site specific Plan should ensure that laboratory hoods are maintained/air flow calibrated If applicable, documented employee training is required on:  Hazard communication  Lab safety  Material Safety Date Sheets (MSDS)  Personal Protective Equipment (PPE)

General Safety Manual Revised - Sample Management Safety (Policy) Statement Revised Safety Meeting Report Form Revised - Sample Procedure for Incident/Accident Investigation  DA2000 – Must be filled out completely

General Safety Manual Sample Blood Borne Pathogens Policy/First Aid Requirements Sample Bomb Threat Checklist Sample Hazard Communication & Chemical Safety Program

Driver Safety Audit Components: Program Inspection & Repair Training Records & Forms

Driver Safety Audit “Program” Requirements: Requires written policies and procedures on all of the following topics:  Enrolling employees to drive  High risk drivers  Driver training  Disciplinary action  Claims reporting  Accident investigation  Identification of state vehicles

Driver Safety Audit “Inspection & Repair” Requirements: Number of vehicles in fleet Documentation of preventive maintenance required

Driver Safety Audit “Training” Requirements: Refresher training required within 90 days for all employees receiving a conviction

Driver Safety Audit “Records & Forms” Requirements: Authorized OR unauthorized driver list must be signed and dated Driver Accident Report Form (DA2041) – must be faxed/ ed within 48 hours to ORM Claims Transportation Unit Supervisor

Driver Safety Manual Sample procedure for authorizing drivers Instructions on how to review an Official Driving Record (ODR) Revised DA 2054 – Authorization & Driving History Form Sample Vehicle Checklist

Bonds & Crime Audit Components: Program Employee Responsibility Security Key Control Internal Audits

Bonds & Crime Audit “Program” Requirements: Written program must contain the following components:  Separation of duties  Inventory control (including disposal)  Purchasing  Reporting losses/damages  Investigation of losses/damages  Timely reporting of losses to the correct ORM claims unit  Handling negotiable items  Securing vaults/safes  Employee responsibilities

Bonds & Crime Audit “Program” Requirements: cont. Comprehensive written security plan/policy must include, but is not limited to, procedures that address the following components:  Monitoring/controlling visitor access  Securing all entrances and exits, both day and night  Security system in place for all entry points  Securing equipment located within agency buildings  Limiting access to data on personal computers

Bonds & Crime Audit “Key Control” Requirements: Written site-specific program must include the following:  Key/card log  Procedures to change locks/codes  Assigning responsibility for the program  Methods for issuing, returning, and accounting for lost/stolen keys/cards  Specific employee responsibilities/procedures for handling keys/cards

Bonds & Crime Audit “Internal Audit” Requirements: No revisions made

Bonds & Crime Manual Sample Key Control Policy/Procedure Sample form – Authorization for Building Access Card and/or Building Office Key

Equipment Management Audit Components: Program Personal Protective Equipment (PPE) Work Order System Lockout/Tagout (LO/TO) Boilers Elevators & Fire Service Key/Equipment Room Confined Space

Equipment Management Audit “Program” Requirements: A written preventive maintenance schedule is required for mechanical and electrical equipment Schedule must include testing procedures on all equipment

Equipment Management Audit “PPE” Requirements: Written procedures must address procurement, use, maintenance, and disposal of PPE for the following:  Head, face, eyes, and ears  Torso  Extremities  Hands and feet  Respiratory System

Equipment Management Audit “Work Order System” Requirements: Written work order procedures must cover the following:  Scheduled preventive maintenance  Reported problems  Emergency problems Repairs must be made in a timely manner and documented Employee training required on work order procedures

Equipment Management Audit “Lockout/Tagout” Requirements: No revisions made

Equipment Management Audit “Boiler” Requirements: All items cited in the boiler inspection report must be corrected and documented

Equipment Management Audit “Elevators & Fire Service Key” Requirements: Elevators:  Certificates must be readily available Fire Service Key  Written procedures outlining the availability  Must be provided to the designated personnel  Provided to the local fire department or readily accessible upon their arrival

Equipment Management Audit “Confined Space” Requirements: Has a documented assessment been performed to determine if confined spaces exist? Written program must cover the following:  Training  PPE  Rescue  Environmental testing  Permits Training required on all components

Equipment Management Manual Sample Lockout/Tagout Policy Sample Lockout/Tagout Inspection Form Sample Lockout/Tagout Procedure

Water Vessel Audit Components: Program Inspections & Repairs Training Records & Forms

Water Vessel Audit “Program” Requirements: Written program needs to include the following components:  Procedure for authorizing employees  Definition of high-risk operators  Procedure for determining high-risk operators  Operator training  Disciplinary action  Claims reporting  Accident investigation procedures  Definition of State water vessels

Water Vessel Audit “Inspections & Repairs” Requirements: Monthly inspections, using a written checklist, are required on BOTH powered and non- powered vessels

Water Vessel Audit “Inspections & Repairs” Requirements: cont. Inspection checklist (for powered and non-powered vessels) must include the following items:  Fire extinguisher  Personal Flotation Device (PFD)  Sound signaling device (e.g. air horn)  Flares  Damage to vessel  Communication device (e.g. radio)  Lighting  Towing trailer

Water Vessel Audit “Inspections & Repairs” Requirements: cont. For all vessels 26 feet or longer, the appropriate Coast Guard inspections shall be conducted as required and all corrective actions performed/documented Preventive maintenance should be performed and documented for vessels of any size

Water Vessel Audit “ Training” Requirements: All authorized employees who receive a conviction for a violation are required to attend (“Boat Louisiana”) refresher training within 90 days of conviction

Water Vessel Audit “Records & Forms” Requirements: The list of approved operators must be signed and dated  List must indicate annual verification of the operator record If accidents occur in a commercial vessel on navigable waters, a Report of Marine Accident, Injury or Death form (CG-2692) must be completed and submitted to the U.S. Coast Guard

Water Vessel Audit “Records & Forms” Requirements: cont. For all accidents the applicable form must be completed and faxed/ ed within 48 hours to the appropriate ORM Claims Unit Supervisor  Passenger Injury Report form (DOTD )  Private Vehicle Report form (DOTD ) Vessels less than 26 feet report to: Claims - Property Unit Vessels greater than 26 feet report to: Claims - Transportation Unit

Water Vessel Manual Passenger Injury Report (Ferry) DOTD – Private Vehicle Report (Ferry) DOTD –

Flight Operations Audit “Program” Requirements: Written plan must follow Federal Aviation Administration (FAA) regulations All accidents require the Aircraft Incident/Accident Statement to be completed and faxed/ ed to the ORM Transportation Unit Supervisor

Flight Operations Manual  Aircraft Incident/Accident Statement

Safety Training The section on Safety Training has been deleted from the manual. All requirements for training have been incorporated into each individual section.

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