REVISED LOSS PREVENTION MANUAL & AUDIT 2007 V-1.0

REVISEDREVISED LOSS PREVENTION LOSS PREVENTION MANUAL & AUDITMANUAL & AUDIT

2007 V-1.02007 V-1.0

KEY DATESKEY 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

INTRODUCTION - INTRODUCTION - MANUALMANUAL

Basic Requirements:

• A comprehensive LP program for all state agencies with fifteen (15) or more employees (Legislation R.S. 39:1543)

• Comprehensive audit once 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!

INTRODUCTION - INTRODUCTION - MANUALMANUAL

• 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.

INTRODUCTION –INTRODUCTION –AUDITAUDIT

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).

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)

AUDITAUDITIntroductionIntroduction


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.




Non-applicable questions will not appear in the on-line version (only)



Cross-reference for questions with the manual


GENERAL SAFETYGENERAL SAFETY

General Safety (GS) -General Safety (GS) -HIGHLIGHTSHIGHLIGHTS

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)

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

General Safety (GS) -General Safety (GS) -HIGHLIGHTSHIGHLIGHTS

GS-HIGHLIGHTS (cont.)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

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


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)


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)



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)



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)



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!



• 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.




• 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)




• 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


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)



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



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)


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



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



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.)


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)


DRIVER SAFETYDRIVER SAFETY

Each agency that provides for the use ofState vehicles by employees to conduct

Official business is expected to adhere tothe requirements of the State’s Fleet

Management Program (Title 4, Part V,subchapter F; Title 34, Part XI of the

La. Administrative Code).

(DS) - HIGHLIGHTS (cont.)(DS) - HIGHLIGHTS (cont.)

Driver Safety (DS) - Driver Safety (DS) - HIGHLIGHTSHIGHLIGHTS

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)

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


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


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



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


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)

(DS) (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)


(DS) (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


BONDS, CRIME, & BONDS, CRIME, & PROPERTYPROPERTY

Bonds, Crime, & Property Bonds, Crime, & Property (BC&P) - HIGHLIGHTS(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.

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



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

BC&P – HIGHLIGHTS BC&P – HIGHLIGHTS (cont.) (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”

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

BC&P – HIGHLIGHTS BC&P – HIGHLIGHTS (cont.)(cont.)

BCP (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


BCP (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)


EQUIPMENT EQUIPMENT MANAGEMENTMANAGEMENT

Equipment Management (EM) Equipment Management (EM) - HIGHLIGHTS- 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)

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)

Equipment Management Equipment Management (EM) - HIGHLIGHTS(EM) - HIGHLIGHTS


• Records will be maintained for the life of all program equipment including, but not limited to:

– Preventive maintenance schedules

– Testing results - Repair documents

– Replacement documents - Service documents



• Documented employee training is required on: (4.1.1.1.12 – 4.1.1.1.15)

– The written program

– Operation of inventoried & testing equipment

– Preventive maintenance duties

– Safety measures, including PPE, to be used when performing PM


EM - HIGHLIGHTS (cont.)EM - HIGHLIGHTS (cont.)

Personal Protective Equipment (PPE):

• Procedures must address the procurement, use, maintenance, and disposal of PPE for specified

body

parts individually (4.1.1.2.1.1 - 4.1.1.2.1.9)

• Assistance and training shall be provided on the above (4.1.1.2.1.10, 4.1.1.2.1.11)

Work Order System:

• Typewritten work order procedures are to be completed for:

– Regularly scheduled PM– Any reported problems– Emergency situations

• Agency shall ensure work is completed and documented in a timely fashion (4.1.1.3.2, 4.1.1.3.3)

• All employees must be made aware of written procedures for reporting problems via the W.O. system (4.1.1.3.4)


EM (cont)

Lockout/Tagout (LO/TO):• A written program is required for any energy

source: (4.1.1.4.1)

– Electrical - Hydraulic - Thermal

– Mechanical - Pneumatic - Radiation

• Must determine and train “authorized” vs. “affected” employees (4.1.1.4.3.1)

• Contractors must furnish their own LO/TO program (4.1.1.4.2.1)

– Agency’s “affected employees” need training either way (4.1.1.4.2)


EM (cont)

Lockout/Tagout:

• Proper LO/To devices shall be available for use by authorize employees (4.1.1.4.4)

– Locks are always the preferred method vs. tags

Boilers:

• Equipment that meets the State’s Boiler Code criteria for inspection will receive such from the commercial carrier, and results sent to the agency & ORM (4.1.1.5.1)


EM (cont)

Boilers:

• Cited items in the boiler inspection report shall be corrected and documented, as well as forwarded to ORM (4.1.1.5.1.2)

• Current boiler certificates must be posted at/near the equipment (4.1.1.5.1.1)


EM (cont)

Elevators/Fire Service/Equipment Room:

• All agency elevators must be inspected at least twice a year by a commercial inspector

– Deficiency reports are available for agency review at:

https://wwwprd.doa.louisiana.gov/bandg_elev

•Agency shall ensure repairs and document (4.1.1.6.1.2)


EM (cont)

Elevators/Fire Service/Equipment Room:

• Current elevator certificates must be posted at/near the equipment (4.1.1.6.1.1)

• Fire service key procedures shall address: (4.1.1.6.1.3 – 4.1.1.6.1.5)

– Availability

– Personnel assigned responsibility for the key

– Providing the key to the local fire dept. representative


EM (cont)

Confined Spaces:

• An assessment to determine/identify location & type of confined spaces (CS) must be performed

(4.1.1.7.1, 4.1.1.7.1.1)

• Unless ALL CS work is contracted out, the agency must develop a program that covers: (4.1.1.7.1.1.2.1–4.1.1.7.1.1.2.5)

– Training - PPE - Rescue - Permits– Environmental testing


EM (cont)

Confined Spaces:

• Definition of confined space:

– Is large enough and so configured that an employee can bodily enter and perform assigned work;

– Has limited or restricted means for entry or exit (e.g., tanks, vessels, silos, storage bins, hoppers, vaults, and pits; and

– Is not designed for continuous employee occupancy


EM (cont)

Confined Spaces:• Definition of permit-required confined

space:

– One that has one or more of the following characteristics:

• Contains/has the potential to contain a hazardous

atmosphere

• Contains a material with the potential to engulf an

entrant


EM (cont)

Confined Spaces:• Definition of permit-required confined space

(cont.):

– One that has one or more of the following characteristics:

• Walls that converge inward or floors that slope downward and taper into a smaller area which

could trap or asphyxiate an entrant

• Contains any other recognized safety or health hazard, such as unguarded machinery,

exposed live wires, or heat stress


EM (cont)

Confined Spaces:

• All necessary CS equipment shall be available prior to commencing work (4.1.1.7.1.1.2.6)

• Must provide training for applicable employees on:(4.1..1.7.1.1.2.7 – 4.1.1.7.1.1.2.11)

- Equipment - PPE - Rescue - Permits

- Environmental testing

• Contractor must have their own CS program (4.1.1.7.1.1.3)


WATERWATER

VESSELVESSEL

Water Vessel (WV) - Water Vessel (WV) - HIGHLIGHTSHIGHLIGHTS

Program:

• An effective program addresses the following areas:

- Responsibilities outlined at each level of the agency

- A detailed operator authorization process

- An effective preventive maintenance (PM) component

- Training

- A system for claims reporting & accident investigation

- Conducting safety audits and maintaining all records


Program:

• There are several required components (5.1.1.1)

- Procedures for authorizing employees as operators

- Defining, determining, & disciplining high-risk operators

- Defining & determining state water vessels- Training operators - Reporting claims- Conducting accident investigations

• The Water Vessel Coordinator or Designee is responsible for monitoring/updating the program (5.1.1.2)

WV - HIGHLIGHTS (cont.) WV - HIGHLIGHTS (cont.)



• A monthly inspection is required for all sizes of powered/non-powered vessels, performed via a checklist on: (5.1.2.1 – 5.1.2.8)

- Fire extinguishers - Flares - Trailers

- Personal flotation devices( PFDs)

- Sound signaling devices - Communication devices

- Lighting - Trailers - Damages




• Corrective actions must be taken & documented based on findings of the inspections (5.1.2.9, 5.1.2.9.1)

• Vessels twenty-six (26) feet or longer must also undergo any additional inspections required by the U.S. Coast Guard, and all corrective actions taken

(5.1.2.10 – 5.1.2.10.1.1)

• Preventive maintenance (PM) shall be performed and documented for any size vessel (5.1.2.11)

WV (cont)

Training:

• Initial DWLF training [“Boat Louisiana”] is required for:

– All authorized operators within ninety (90) days of hire or upon entering the program (5.1.3.1)

– All authorized operators within ninety (90) days of being convicted of a violation (5.1.3.6)

• Refresher training is required otherwise once every three (3) years (5.1.3.4)


WV (cont)

Training:

• Initial Coast Guard training is also required for operators of vessels 26 feet or longer. (5.1.3.2)

• Refresher Coast Guard training is required once every five (5) years thereafter (5.1.3.5)


WV (cont)

Records & Forms:

• Department/Agency heads shall annually:

– Sign and date a list of authorized operators

– Review, sign, and date all Vessel Authorization /Operator History Forms (DA2066)


WV (cont)

Records & Forms:

• For accidents in a commercial vessel over navigable waters, must complete the Coast Guard CG-2692 form

(5.1.4.3, 5.1.4.3.1)

• For accidents involving any non-commercial vessel in any waters, must complete the LDWF (DWF-A-BAIR) form (5.1.4.4, 5.1.4.4.1)


FLIGHT FLIGHT OPERATIONSOPERATIONS

Flight Operations (FO) - Flight Operations (FO) - HIGHLIGHTSHIGHLIGHTS

Program:

• Must have a written program that follows Federal Aviation Administration (FAA) regulations for: maintenance, forms, corrective actions(6.1.1.1 – 6.1.1.2.2)

• For each aircraft incident/accident, an ORM statement must also be completed and faxed/e-mailed within 48 hours to the ORM Transportation Claims Unit supervisor (6.1.1.3.1 – 6.1.1.3.1.1)

• All pilots flying state-owned/authorized aircraft shall have a commercial license (6.1.1.4)

Documents

REVISED LOSS PREVENTION MANUAL & AUDIT 2007 V-1.0