1. FTA Drug and Alcohol Program NATIONAL CONFERENCE You’re Being Audited by FTA - What Should You Expect? Lori DeCoste & Ed VanderPloeg

2. 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"

3. Background FTA audits approximately 45 grantees and states each year  An audit team is in the field 24 weeks out of each year  Rotating cast of auditors, Audit Team Leaders, and federal representatives  Selection 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

4. Background FTA views the audit primarily as:  An opportunity to assess selected grantees’ level of compliance  A chance to offer specific guidance on potential corrective actions  An 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

5. Phases of the Audit Process There are three distinct phases to the audit process: 1.Notification/Pre-Audit 2.Site Visit 3.Post-Audit/Compliance We will discuss each phase in turn

6. 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 audit  Selected dates are firm once agreed upon  Basic overview of audit process and information needs  Overview of schedule/deadlines for the next seven weeks  Identification of contractors/sub-recipients (as applicable)  Try to put the DAPM at ease – although this rarely works!

7. 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

8. Pre-Audit As soon as possible after notification, DAPM will:  Notify key individuals within the organization of the audit  Notify contractors and vendors of the audit  Share notification letter as needed  Begin gathering the pre-audit information package (due 3 weeks from initial call) Careful preparation at this stage helps ensure a smooth onsite experience

9. 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 Policy 2.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-up 4.Contact information for MRO and SAP 5.Completed schedule with addresses and contact information for grantee, contractors, collection site 6.Other materials specifically identified in notification letter Pre-Audit

10. 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 pieces 2.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

11. 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 Leader  SAP interview: 20+ questions / 15-20 minutes  MRO interview: 60+ questions / 30-45 minutes  Usually conducted 1-3 weeks prior to onsite audit  Typical findings: Unaware of certain elements of 49 CFR Part 40 Pre-Audit

12. 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

13. 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

14. 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

15. Site Visit Audit team arrives at the grantee location Entrance interview begins – usually either 9 AM or 1 PM 1.Introductions 2.Overview of audit process/schedule 3.Questions/answers about process 4.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

16. Site Visit Records 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

17. Site Visit Records Review – Pre-Employment Typical findings: Employees placed in SS duty before a negative result is received No test result at all

18. Site Visit Records Review – Random What we look for: Unpredictable spread of random testing  Throughout the year  Days of the week  Hours of the day Valid and recorded excusals

19. Site Visit Records Review – Random Typical findings: Lack of weekend testing Lack of early morning/late night testing Excusals for invalid reasons, or not fully documented

20. Site Visit Records Review – Post-Accident What we look for: Accident meets FTA criteria Decision-making process documented Time limits: 2hr/8hr/32hr rules

21. Site Visit Records 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

22. 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

23. Site Visit Records 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

24. Site Visit Records 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

25. Site Visit Records 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 records  Random testing selection lists  Forms used to document various aspects of the program  Documentation of policy receipt by employees Typical findings: Missing records Inadequate/non-compliant forms

26. Site Visit DAPM 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

27. Site Visit Collection 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

28. 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:

29. Site Visit Wrap-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

30. Site Visit Contractor Site Visits If there are contractors to be audited, auditors visit them the following day(s) and follow the same audit process outlined above  Grantee is fully responsible for compliance of its contractors  Grantee should not assume contractors have full knowledge of the requirements or that their policies/programs are compliant  DAPM often attends contractor site visits Final audit report typically delivered to grantee the morning after the final contractor audit

31. 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 interview  Audit 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

32. Post-Audit Audit Response Policy modified (as applicable), provided to Team Leader for review prior to 90-day deadline  Once “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

33. Post-Audit Review 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!

34. 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.govfta.damis@dot.gov

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

36. FTA Drug and Alcohol Program NATIONAL CONFERENCE THANK YOU Atlanta, GA 2015