REVISED LOSS PREVENTION MANUAL & AUDIT 2007 V-1.0

1. REVISED LOSS PREVENTION MANUAL & AUDIT2007 V-1.0

2. KEY DATES • 2/1/08 – ORM Web Site Updated • Word version of new manual & self-audit • FAQ’s (w/periodic updates) • Comments/suggestions link (preferred method) • 7/1/08 - Compliance Reviews, using old/current self-audit, on activities of FY 07-08 - Effective date of new requirements • 7/1/09 - Audits, using new self-audit, on activities of FY 08-09

3. INTRODUCTION - MANUAL Basic Requirements: • A comprehensive LP program for all state agencies with fifteen (15) or more employees (Legislation R.S. 39:1543) • Comprehensive auditonce every three (3) years (Act 11, Extraordinary Session 1998, R.S. 39:1543) • Compliance review conducted during non-audit years • Self-audit must be completed and available by the time of the audit OR compliance review • If not, agency will NOT pass the audit!

4. INTRODUCTION - MANUAL • All employees must be made aware of the departmental or agency site-specific LP plan during orientation. • documentation of what is included in the orientation (1.1.1.3) • each location to maintain at least one hard copy of the plan or provide electronic access (1.1.1.4) • Sample policies and procedures are included only as examples to be used in writing individualized plans • “Shall” & “Must” denote obligatory action and are prevalent throughout the manual.

5. INTRODUCTION –AUDIT Old Audit: - Questions were very vague/general. - Determination of compliance by LP Management often based upon the LPO’s interpretation of whether or not the manual requirements were met. New Audit: - Questions similar, but more expanded and objective. - This is achieved by asking specific/detailed questions of all aspects of all programs with a yes or no answer (in most cases).

6. INTRODUCTION –AUDIT AUDITIntroduction Layout Differences: • Questions are more direct -’s: more ?s to answer +’s: pinpoint efforts & minimizes points • Numbering system is “layered” 1 = General Safety 4 = Equipment Management 2 = Driver Safety 5 = Water Vessel 3 = Bonds, Crime, & Property 6 = Flight Operations • Example: 1.1, 1.1.1, 1.1.1.1 • Dictated by the scoring software • Non-applicable questions will not appear in the on-line version (only)

7. AUDITIntroduction INTRODUCTION –AUDIT WHAT ARE “CLASS A” AND “CLASS B” AGENCIES? • The class in which an agency is categorized by ORM is determined by its most recent accrual rate. • Class A agencies are those with a rate at $5.00 or higher and are required to conduct safety meetings and inspections on a monthly basis. • Class B agencies are those with a rate below $5.00 and are required to conduct safety meetings and inspections on a quarterly basis.

8. AUDITIntroduction INTRODUCTION –AUDIT • Non-applicable questions will not appear in the on-line version (only)

9. AUDITIntroduction INTRODUCTION –AUDIT Cross-reference for questions with the manual

10. GENERAL SAFETY

11. General Safety (GS) -HIGHLIGHTS Program: • Begins with a strong show of support from top management via Management Policy Statement (1.1.1.2) • Commitment to safety for employees & clients • Outlines mgt. expectations and employees’ responsibilities • Details system of accountability for not adhering to the responsibilities (1.1.2.2)

12. General Safety (GS) -HIGHLIGHTS Program: • Safety responsibilities • must be presented to all employees initially and whenever assigned to a position with different or additional duties(1.1.2.1) • Safety rules (1.1.3 – 1.1.4.1.1) • shall be developed, distributed and documented by each agency & reviewed/posted annually • General for all employees • Site/task specific as needed

13. GS-HIGHLIGHTS (cont.) Safety Meetings & Training: • # of safety meetings conducted in 3 years [more mtgs. = higher score] (1.2.1.1 - Class A, 1.2.2.1 - Class B) • Must achieve the minimum of 75% attendance at every meeting (1.2.1.2 - Class A, 1.2.2.2 - Class B) • Department &/or Agency Head must attend all meetings to show support (1.2.1.3 – Class A, 1.2.2.3 – Class B) • A record of specifics relating to each safety meeting must be kept for three (3) years (see p. 7) • Materials covered must be made available to all employees who could not attend

14. GS-HIGHLIGHTS (cont.) Safety Meetings & Training: • Must have written policies and documented training for Drug Testing & Substance Abuse and Sexual Harassment (1.2.3, 1.2.4.1-1.2.4.4) • w/in 1 yr. of hire & at least once every 5 years • May count toward the monthly/quarterly meeting • Safety Committee not mandatory, but if one exists, then must meet and must document attendance and topics (1.2.5 - 1.2.5.2) • Recommended for agencies with 15 or more employees • Meetings quarterly/monthly based on agency class

15. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Safety Meetings & Training: • The agency’s designated Loss Prevention Coordinator (LPC) must receive documented (formal, OJT) training on: (1.2.6, 1.2.7) • Acc. Investigations, Inspections, Safety Meetings, Supervisor Responsibilities, and JSAs • The agency’s designated LPC must provide documented (formal, OJT) training to all field representatives on the above (1.2.8, 1.2.9)

16. GS-HIGHLIGHTS (cont.) Safety Meetings & Training: • All coordinators/representatives must attend training on the ORM LP Program 1x/three (3) years (1.2.10) • Additional, documented training for those who “perform new tasks or operate new equipment, or whose safety performance is unsatisfactory” (1.2.11)

17. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Inspections: • % of inspections conducted in 3 yrs. [high % = high score] (1.3.1.3 - Class A, 1.3.2.3 - Class B) • A written report shall be kept for three (3) years for each inspection, outlining the unsafe acts/conditions and the recommended corrective actions • Site-specific checklists strongly recommended (1.3.1.4-1.3.1.4.2 – Class A, 1.3.2.4-1.3.2.4.2 – Class B)

18. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Inspections: • Employees must notify management of hazards, via the hazard control log (HCL) or other acceptable method, for immediate corrective action (1.3.1.5 - Class A, 1.3.2.5 – Class B) • Correction of hazards (checklist or HCL) shall occur in a timely manner (1.3.1.6 – Class A, 1.3.2.6 – Class B) • Hazards not corrected after 30 days must be referred to agency head & ORM • Reports shall be retained for a minimum of three years • Hazards found during a Fire Marshal inspection shall be corrected immediately (1.3.3, 1.3.3.1)

19. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Incident/Accident Investigation: • Agency shall fill in the proper form: (1.4.1, 1.4.3.1) • DA 2000 (state employees only); DA3000 (visitors, clients) • Completed forms must be reviewed for accuracy and retained (1.4.3.1.1, 1.4.3.1.2) • Root cause analysis information required • “N/A” unacceptable • Injuries from a vehicular accident shall be recorded on the DA2041 form ONLY---NOT the DA2000!

20. GS-HIGHLIGHTS (cont.) Incident/Accident Investigation: • Agency shall report on-line all DA1973/LDOL-OWC-1007 (E1 – First Report of Injury) forms to the appropriate ORM Claims unit within the required reporting time frame established by the respective unit(s). • The ORM Loss Prevention Unit shall be contacted immediately for a fatality or near-fatality.

21. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Incident/Accident Investigation: • Job Safety Analysis • JSAs are the responsibility of the immediate supervisor or designee • JSAs shall be performed on all tasks that have resulted in an incident/accident trend, death, or a change in job procedures or equipment (1.4.4.1)

22. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Incident/Accident Investigation: • Job Safety Analysis • Documented employee-training on completed/existing JSAs should be conducted at least annually(1.4.4.2) • Completed JSAs should be kept in an area accessible to all employees for review purposes (1.4.4.3) • It is strongly recommended that the agency review all applicable JSAs after any incident/accident

23. GS-HIGHLIGHTS (cont.) Recordkeeping: (1.5.1, 1.5.2) • Agencies are required to maintain the following records: • For 3 years: • Inspection reports •Hazard control logs •JSAs • Safety meetings •Accident/incident investigations • For 5 years: • Safety training (BBP, Sexual Harassment, Drug Testing/Substance Abuse)

24. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Blood Borne Pathogens: All agencies must now have a written program that addresses: (1.6.1 – 1.6.1.2) • Exposure determination • Methods of compliance • Medical Evaluation for affected employees • Work practice controls • Training

25. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Blood Borne Pathogens: • Training required: • for low risk employees within twelve (12) months of hire and at least once every five (5) years thereafter (1.6.2.1) - for high risk employees within three (3) months of hire and at least once every year (1.6.2.2) • Spill procedures shall be in place and spill kits maintained (1.6.4, 1.6.5)

26. GS-HIGHLIGHTS (cont.) First Aid: • All agencies shall have a written program that addresses the needs of employees and visitors (1.6.6) • If not in close proximity to medical assistance, each agency location should provide at least one person trained in CPR/first aid when: (1.6.8) • There are night shifts or minimal/partial crews • Medical facilities are closed • Field crews are working at points far removed from professional help

27. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Emergency Preparedness: • Agencies must have a written plan that addresses: (1.7.1 – 1.7.1.5) • fire, natural disasters, proximity threats, and terrorism • Fire drills must be conducted at least once per year (1.7.2) • Even if a leased space

28. GS-HIGHLIGHTS (cont.) GS-HIGHLIGHTS (cont.) Hazardous Materials: • Each agency must conduct a complete inspection in order to determine the presence of hazardous materials (1.8.1) • “Hazardous” means: • “physical hazard” (flammables, explosives, etc.) • “health hazard” (carcinogen, hepatogen, mutagen, etc.)

29. GS-HIGHLIGHTS (cont.) Hazardous Materials: • If present, then a written program must be developed and address: (1.8.1.1) • Proper handling, storage, and disposal (1.8.1.1.2 – 1.8.1.1.4) • Availability of storage cabinets, MSDSs, and PPE (1.8.1.1.5 – 1.8.1.1.7) • Training will cover, at a minimum: (1.8.1.2 – 1.8.1.5) • HazCom program, Lab safety, MSDSs, PPE • Lab hoods must be maintained and air flow calibrated (1.8.1.1.8)

30. DRIVER SAFETY

31. (DS) - HIGHLIGHTS (cont.) Each agency that provides for the use of State vehicles by employees to conduct Official business is expected to adhere to the requirements of the State’s Fleet Management Program (Title 4, Part V, subchapter F; Title 34, Part XI of the La. Administrative Code).

32. Driver Safety (DS) - HIGHLIGHTS Program: • A written program is required and shall cover: • Authorized/Non-authorized drivers • State vehicles vs. personal vehicles • High-Risk drivers (define, identify, discipline) • Manager, supervisor, and employee responsibilities • Someone should be assigned to monitor the program for compliance and updates(2.1.2)

33. Driver Safety (DS) - HIGHLIGHTS Program: • Manager/Dept./Agency Head/Designee Responsibilities: • Verify possession of and proper class of license • Ensure drivers have completed defensive-driver training • Review ODR & sign the DA2054 • Inform supervisor(s) of approved/non-approved list

34. Driver Safety (DS) - HIGHLIGHTS Program: • Supervisor Responsibilities: • Provide time for authorized employees to complete the defensive driver training • Ensure all incidents/accidents are reported and documented • Verify proof of insurance for authorized drivers • Make sure state vehicles are in proper working order, addressing/documenting deficiencies in a timely manner

35. Driver Safety (DS) - HIGHLIGHTS Program: • Employee Responsibilities: • Safely operate all vehicles for which they are approved • Report any unsafe condition or accident involving state vehicles to their supervisor or designee(for personal vehicles, report accidents only) • Show proof of insurance & complete the DA2054 • Report any moving violation, accident and/or revocation immediately to the supervisor and driving coordinator

36. Driver Safety (DS) - HIGHLIGHTS Inspections & Repairs: • For state-owned vehicles, must : (2.2.1 – 2.2.1.3) • Complete a monthly inspection checklist • Take corrective actions on and document findings • Perform and document preventive maintenance

37. (DS) - HIGHLIGHTS (cont.) Training: • Must provide documented defensive-driver training for all agency employees authorized to drive on state business • Within ninety (90) days of hire (2.3.2) • Refresher training once every three (3) years (2.3.3) • Authorized employees convicted of a violation must attend refresher training within ninety (90) days of conviction (2.3.4)

38. (DS) (cont) (DS) - HIGHLIGHTS (cont.) Records & Forms: • Agencies must maintain the following forms annually: • a list of either authorized or unauthorized drivers [signed & dated](2.4.1) • DA2054 - Driver authorization forms [signed & dated] (2.4.2) • Official driving records [reviewed only] (2.4.3)

39. (DS) (cont) (DS) - HIGHLIGHTS (cont.) Records & Forms: • For each vehicular accident during the three (3) year audit period: • Driver must complete a DA2041 form [Driver Accident Report Form] for any vehicle - state or personal (2.4.4.1) • Each completed DA2041 must be faxed or e-mailed to the ORM Transportation Claims' Supervisor within forty-eight (48) hours (2.4.4.1.1) • A copy of the police report shall be submitted to ORM Claims unit as soon as available

40. BONDS, CRIME, & PROPERTY

41. Bonds, Crime, & Property (BC&P) - HIGHLIGHTS • Conformance by an agency with all Office of Statewide Reporting and Accounting Policy (OSRAP) policies regarding fiscal controls and safeguards shall satisfy ORM’s requirements • ORM guidelines are not a substitute for OSRAP guidelines. • Agencies shall be responsible for complying with any other ORM requirement or exception not specifically addressed by OSRAP policy.

42. Bonds, Crime, & Property (BC&P) - HIGHLIGHTS Each agency shall establish a system of internal accounting and administrative controls in accordance with applicable Federal and Louisiana State Statutes and regulations utilizing the following guidelines: • Reasonable Assurance - Competent Personnel • Internal Control Guidelines - Documentation • Separation of Duties - Supervision • Access to Resources - Address Audit Findings

43. Bonds, Crime, & Property (BC&P) - HIGHLIGHTS Program:(3.1.1 – 3.1.9) • The agency’s program must address the documentation and/or prevention of property damages and losses • The written procedures shall address, at a minimum: -separation of duties - controlling inventories - purchasing - securing vaults/safes - reporting and investigating losses/damages - timely reporting of losses to the correct ORM claims unit

44. BC&P – HIGHLIGHTS (cont.) Responsibilities: • Department heads or their designees are responsible for reviewing the fiscal control program regularly for efficiency and effectiveness. (3.1.10) • Only employees authorized to “manage” state assets shall be assigned duties under the BC&P program and receive documented training on such (3.2.1.1, 3.2.1.2) • Manage is defined as including “approval of transactions and/or directing the approval of transactions”

45. BC&P – HIGHLIGHTS (cont.) Security: (3.3.1 – 3.3.6) • The written security policy must address: • Limiting and monitoring access by authorized individuals • securing and alarming all entrances and exits [24 hours] • securing equipment within buildings • limiting access to data on personal computers

46. BCP (cont) BC&P – HIGHLIGHTS (cont.) Key Control: (3.4.1.1) • The program must cover the following concerns: • Key/card Log - Changing locks/codes • Assigning responsibility for the program • Issuing/returning/accounting for lost or stolen keys/cards • Employee responsibilities in handling key/cards

47. BCP (cont) BC&P – HIGHLIGHTS (cont.) Audits: • Must conduct regular internal audits at the various stages of the business process[e.g., petty cash, inventory] (3.5.1) • The Agency shall ensure records are reconciled at least annually. • Dept/Agency Heads to evaluate and respond to the Internal and/or Legislative Auditor’s findings and recommendations expeditiously.(3.5.1.1, 3.5.1.2)

48. EQUIPMENT MANAGEMENT

49. Equipment Management (EM) - HIGHLIGHTS Program: • A written program is required for all agencies housed in a state-owned building that have electrical and/or mechanical equipment (4.1 – 4.1.1.1.3) • A detailed inventory must be maintained, to include: name of the equipment, location, model number, and serial number (4.1.1.1.4)

50. Equipment Management (EM) - HIGHLIGHTS Preventive Maintenance: • Agencies must have PM procedures and schedules, whether they follow the manufacturer’s recommendations or use the samples from ORM in the manual. (4.1.1.1.5 – 4.1.1.1.7) • All PM (repairs, testing, etc.) must be documented, in typewritten form, for mechanical & electrical equipment (4.1.1.1.8 -4.1.1.1.11)