HomeMy WebLinkAboutFCS-13-084 - 2nd Quarter Audit Status ReportI
Staff Report
finance and Corporate Services Department wvmkitchener ca
REPORT TO:
Audit Committee
DATE OF MEETING: June 24, 2013
SUBMITTED BY:
Corina Tasker, Internal Auditor, 519 - 741 -2200 EXT 7361
PREPARED BY:
Corina Tasker, Internal Auditor, 519 - 741 -2200 EXT 7361
WARD(S) INVOLVED: ALL
DATE OF REPORT: June 14, 2013
REPORT NO.:
FCS -13 -084
SUBJECT:
2nd QUARTER AUDIT STATUS REPORT
RECOMMENDATION:
For information only.
EXECUTIVE SUMMARY:
The following report provides a summary of the Internal Audit activities completed during the
period of March 2013 to June 2013. The chart below shows the audits and other work
contained in this report.
AUDIT
Division /Topic Scope
Emergency Management Program Comprehensive
The following 2012 and 2013 work plan items are currently in progress and will be brought
forward at a future audit committee meeting in 2013:
• Operations review
• The Aud and Arenas audit
BACKGROUND:
The Internal Audit 2013 work plan was approved during the audit committee meeting held on
December 3, 2012. This report provides a summary of the work completed during the 2nd
quarter of 2013.
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REPORT:
Emergency Management Program — Comprehensive Audit
Status: Complete, April 8, 2013
Audit Objectives:
The Emergency Management and Civil Protection Act (2006) or EMCPA is provincial legislation
which sets standards which municipal emergency management programs must comply with.
The EMPCA indicates that municipal emergency management programs must:
• Designate a community emergency management coordinator (CEMC);
• Have an emergency response plan;
• Have a hazard identification risk assessment (HIRA);
• Conduct annual training and exercise programs;
• Identify critical infrastructure in the municipality; and
• Have a public education and awareness program
Ontario Regulation 380/04 Part II also sets standards which each municipality must meet. In
addition to those items listed above, each municipality shall establish a community control group
(CCG) and an emergency operations centre (EOC).
The objective of this review was to assess the City's emergency management program. The
review tested the following components of the program to ensure that the program not only
meets legislative requirements but also provides a framework which is understood by staff and
can easily be put into action should a real emergency occur. Municipalities could have the best
plan on paper but fail in the field if staff are not knowledgeable about the plan contents or have
not had opportunities to test their knowledge in action. This audit aims to assess the City's
readiness and capability to deal with emergency situations.
Program components tested:
• Governance
• Assessment
• Planning
• Training and Awareness
• Emergency Exercises (Simulations)
• Maintenance
Methodology:
The following research and analysis was undertaken for this review:
• Staff interviews — 22 City of Kitchener staff with emergency management responsibilities
were interviewed to gain an understanding of their roles, level of training, the strengths of the
emergency management program as well as areas for improvement. These included all
members of the Community Emergency Management Program Committee (CEMPC) as well
as others who played a role during the October 2012 training simulation.
• External interviews — 3 interviews were held with external agency partners and 2 interviews
were held with emergency management managers from other organizations.
• Participation in the October 2012 training simulation as an observer.
• Internal literature review of the City's emergency plan and all relevant appendices or related
documents.
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• External literature review including relevant legislation and standards, audits done by other
municipalities, and conference material related to emergency management.
• Completion of the Basic Emergency Management and EOC training courses.
• Attendance at the "Goderich Experience" training session.
• Tour of the EOC and proposed alternate EOC.
• Review of emergency management information on the City's internet and intranet.
Summary of Audit Results:
The City of Kitchener was found to be in compliance with the applicable emergency
management legislation. The emergency program is well thought out, has a comprehensive
and well understood plan, and a committed team of individuals to execute the plan. The
positive results of this audit provide assurance that the citizens of Kitchener are in good hands
should a major emergency occur. While there is no doubt in the auditor's mind that the City
would be able to successfully deal with a large scale emergency, there are a few risk exposures
which need to be addressed and several areas where minor improvements to the program could
be made to bring the program to an even higher level of effectiveness.
Many of the recommendations contained in this report are minor in nature. The most critical
recommendations focus on improving staff knowledge and level of training, and clearly
understanding roles and responsibilities to a detailed level. This also includes ensuring there
are trained backups for every role.
In addition, is important that the Fire Department provide dedicated administrative support to the
CEMPC in order to handle the workload associated with assembling the annual legislative
compliance documentation and supporting the annual exercise planning and execution.
Currently this is being done by a volunteer and is not sustainable.
By implementing these recommendations the CEMPC will be able to continue to improve on an
already excellent program.
Findings and Recommendations:
Governance
The City of Kitchener has a Council resolution which establishes the emergency program and a
by -law to establish the emergency plan which governs the provision of necessary services
during an emergency. Currently the program complies with the standards and legislation set out
by the Emergency Management and Civil Protection Act. Ontario Regulation 380/04.
As part of the research for this audit "Canadian Standard Z1600 -08, Emergency Management
and Business Continuity Programs" was reviewed. It is a standard which applies to public, not -
for- profit, and private entities in Canada. It outlines the requirements for a comprehensive
emergency management program. The standard establishes elements of a continuous
improvement process to develop, implement, maintain, and evaluate emergency management
and business continuity programs that address prevention and mitigation, preparedness,
response, and recovery.
Standard Z1600 -08 includes all of the aspects in Ontario Regulation 380/04 with the addition of
several other requirements which bring the program to a more comprehensive level.
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Recommendation:
• Although it is not necessary to comply with Standard Z1600 -08 it is recommended that
the CEMPC review the standard for suggestions in which to continuously improve the
City's program. This standard could also be used as a starting point for the business
continuity plan which is still in progress.
There is strong senior management support for the program and adequate budget to support
the needs of the program. A key success factor of the program is the dedication of the
volunteer members of the CEMPC. Their strong commitment and passion for emergency
management has ensured that the program has moved beyond minimum requirements in many
areas. There is currently a large amount of administrative work which is being carried out by
one of the volunteers. This is not sustainable in the long run.
Recommendation:
Obtain administrative support both for monthly CEMPC meetings as well as for help with
exercises and pulling together the annual legislative requirements. This ideally should
come from within the Fire department as the responsibility for emergency management
rest with that division. If possible an existing resource should be utilized, adding these
responsibilities into the job description. If current resources do not have capacity, then
thought should be given to creating a part time position if budget allows or partnering
with the City of Waterloo to share a resource.
Assessment
The identification of community hazards was comprehensive and clear in identifying what
potential events are most likely to occur in the City of Kitchener, allowing staff to plan
accordingly. In addition the prevention and mitigation efforts to address these hazards appears
to be adequate and successful where tested.
The critical infrastructure within the City was also clearly identified. The legislation requires that
critical infrastructure be identified but does not require that mitigation plans be put in place. Many of
the critical infrastructure institutions and businesses do have business continuity plans or fire safety
plans in place which have been approved by the Kitchener Fire Department.
Recommendation:
The critical infrastructure listing could be improved by indicating which businesses have
current business continuity plans or fire safety plans in place. This will help the City identify
any potential risks and then set the ground work for discussions with any businesses which
lack plans. It is not the City's responsibility to ensure that they do have plans but it would be
in the City's best interest to start the dialogue and impress upon them how important it is to
have a plan, providing support or guidance where necessary.
Planning
The City has a variety of different plans to prevent, mitigate, prepare and respond to
emergencies. The areas that are lacking any formalized and consolidated plan are the recovery
and business continuity aspects of emergency management. The CEMPC has put the creation
of a recovery plan on their 2013 work plan and have a draft prepared. There is a cross -
functional committee looking at business continuity planning; however, this work had been put
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on hold temporarily due to a key staff vacancy. A one -year secondment position has now been
created to take over management of this project.
The Emergency Plan itself is well laid out, easy to understand, and covers most of the major
responsibilities which are required during an emergency response. Staff have been provided
recommendations for small improvements to the plan.
There is integration between the facility and community emergency plans. The facility
emergency plan, which instructs staff at every facility what to do when faced with a variety of
different facility specific emergencies, compliments the community plan and provides specific
response plans for emergencies within City facilities. Each facility has their own facility
emergency response team (FERT) who report to a specified command post during an
emergency. In addition, the Facility Emergency Preparedness Coordinator sits on both the
CEMPC and coordinates all of the FERT teams which provides the link and the knowledge
transfer between the two plans.
A corporate wide business continuity plan (BCP) does not currently exist so obviously there is
no integration with the community emergency plan. The BCP team has assembled a list of
critical services which would need to maintain operations in the event of a business interruption,
disaster, or emergency. As the BCP is drafted consideration should be given to how to keep the
City and its services running in the event of an emergency. For example, if a large contingent of
staff , such as Fire or Operations personnel, are involved in responding to the emergency there
should be mechanisms put in place to ensure that there are enough Fire and Operations staff to
respond to other regular fire or operations related issues. Thought should also be given to what
needs to happen to ensure the EOC and site personnel can continue to function including
technology, facility and human factors.
Recommendation:
• Make specific reference in the BCP to how the EOC and emergency operations will be
supported and maintained throughout an emergency.
The Facility Emergency Management Coordinator sits on the regional team which meets four
times per year. This provides a link between what the City does internally and what our partner
agencies are doing. The partner agencies are also invited to the annual training exercise so
that everyone gets a chance to work together and build relationships. The emergency plan
contains the Grand River Conservation Authority Flood Warning plan, Region of Waterloo levels
of response and alerting system, and both public and Catholic school board emergency plans
as appendices.
Recommendation:
• To further strengthen relationships and clarify roles between the City and the agency
partners meetings between various groups should be held throughout the year. This
would serve to allow the individuals to work through process inefficiencies, role
ambiguities and protocols outside of the annual training exercise.
The Emergency Operations Centre (EOC) and alternate EOC were evaluated against criteria
provided by the Canadian Emergency Management College in terms of what makes an ideal
EOC. In general the EOC should have resiliency and redundancy built in, cater to the safety
and physical comfort of the Community Control Group (CCG) and be equipped with appropriate
technology and supplies. Most of the criteria for an ideal EOC were met for both the primary
and alternate EOC locations.
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Recommendations:
• 72 -hour kits including bottled water should be prepared and stored at both locations with
enough supplies to cover all CCG staff. Food and drink would need to be rotated
annually and could be donated to the local food bank. If the storage of such quantities
of food is not feasible, at a minimum there should be a coffee maker, kettle, coffee, tea,
soup, water and energy bars available. The City should not depend on the availability of
food delivery as businesses may be closed during an emergency which includes a
power outage.
• Contact information for the Building Operator and backups should be included in the
EOC kits or in the Emergency Plan appendices in order to quickly address inside air
quality and temperature issues.
• Evacuation procedures / exit locations and communication of who the fire warden is
should be provided to all CCG members as they enter the EOC and / or during the first
planning cycle.
• Given that the EOC bins contain private information such as home phone numbers the
storage cabinets should be locked at all times to protect this information. This
information should also not be included in the appendices to the plan posted on the
intranet.
• The amateur radio equipment should be tested on an annual basis to ensure it is in
working order.
Training and Awareness
Overall the range of experience and training for the key roles is quite good with only a few weak
spots in areas where there has been recent turnover. It is imperative that new staff get the
required training so that they can function effectively as part of the team.
There are several key roles which do not have adequately trained backups who would be
comfortable taking over those roles. This is a risk which can be mitigated through additional
training, mentoring, and allowing those individuals to either observe or participate in future
training exercises. According to Sal Liefrieri of Countermeasures Inc., statistics show that on
average only 1 in 5 employees show up for work during a major emergency. It is critical to have
appropriate backups in place in case people are unable to come into the EOC or in situations
where the emergency lasts several days and staff need to be relieved.
The courses and training that the staff have taken were not recorded anywhere and there was
no easy way of retrieving this information other than through the interviews. Keeping an
accurate record of the types and dates of training is key to ensuring that training is current and
in aiding with assessing training needs.
Recommendations:
At a minimum, all CCG and CEMPC members should take the online self -study course
in order to become familiar with all roles, terminology and command structure.
Given that there is a significant need for Basic Emergency Management training (7 core
staff plus additional backup staff) the City should investigate holding another training
session locally in partnership with any of the surrounding municipalities who wish to
participate.
Backup assignments for all CCG roles should be identified and the staff adequately
trained. Thought should be given as to how to involve the backup roles in future training
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exercises. For example, having a few of the key roles not be able to report to the EOC
or quit half way through as one of the simulation inputs.
Record all courses taken to date in PeopleSoft.
Continue providing annual emergency program overviews to staff and management in each
department. Include a wide range of participants in order to broaden the awareness and add
to the backup pool.
Ensure that Council has their own program overview each year to broaden awareness as to
what is required in an acting -Mayor role.
The City of Kitchener provides education to the public on how to prepare themselves for an
emergency through two main channels: 1) emergency preparedness training for Grade 6 students
through the Children's Safety Village; and 2) through direct mail campaigns to 10,000 homes
annually. These methods are effective and provide good coverage.
Another channel which has not been fully utilized is the use of the internet and social media. While
the City does have a link to the Emergency Plan on the internet, other types of emergency
management content is limited. There is an opportunity to expand the reach of emergency
management messaging by providing more rich content such as online versions of the direct mail
brochures on specific topics, links to the Safety Village web page, and downloadable emergency kit
checklists. There is currently a link to the Safety Village page but it is in another area of the City's
website and not associated with the emergency management pages. The link for "Emergency
Preparedness — Personal" also only links to the City's emergency plan and not to any sort of plans or
checklists that an individual could use. The City's social media feeds such as Twitter and Facebook
could be used to further advertise Emergency Management Week or any other special events.
Recommendations:
• Better leverage the use of the City's internet site and social media feeds to create awareness
about emergency preparedness.
Emergency Training Exercises (Simulations)
The exercises which have been conducted over the past 5 years have covered a wide range of
scenario inputs such as possible pollution of the water, casualties and injuries, unknown hazardous
material spills, change in wind direction and evacuation of the primary EOC, weather conditions,
evacuation of citizens, and traffic control to name a few. The exercises have tried to simulate real
conditions while testing as many of the roles and responsibilities as possible. Four of the five
exercises (not including pandemic planning) included hazardous materials. Future exercises should
perhaps branch out into other topics. The CEMPC does not have a long range plan for training
exercises. The 2013 exercise will focus on recovery.
Recommendations:
• The CEMPC should take some time to create a 5 year exercise plan incorporating both large
simulations and smaller targeted table top exercises or workshops. They should continue to
cover the highest rated hazards and involve as many people as possible to ensure
knowledge and awareness is spread deeper than the director or manager level.
• In particular, CCG call -outs, moving to the alternate EOC and calling in backup staff should
be tested.
• Budget should be allocated at the end of the 5 year cycle to conduct a full site and EOC
simulation.
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The 2012 training exercise was very well planned and executed. Participants appreciated the ability
to get together in this type of setting to practice their skills, build relationships, and work on
collaboration. It is the auditor's opinion that the participants did a far better job of responding to the
emergency in an organized fashion than in the 2010 exercise which had been observed. For the
most part they knew their roles and responsibilities and were able to take action where required. The
CAO did a great job of facilitating the planning cycles, especially since this was his first time in this
role. The participants did their jobs well in order to quickly and calmly assess the situation and take
decisive action.
Even though the exercise was executed successfully, there is always room for improvement. The
following is a summary of the suggestions for improvement made during the debrief session, through
the observer surveys and through interviewee feedback.
Recommendations:
The EOC Chair should have a list of housekeeping items which are mentioned at the
beginning of every exercise or emergency such as:
o Location of offices including any additional agencies not on the standard map
o Evacuation instructions and identification of the EOC fire warden
o Location of alternate EOC and process to convene there
o Explanation of the how to use the phone and microphone systems, how to login to
the computer systems and the location of the printer and fax
o Instructions for filling in personal log books
• Consider and evaluate the use of more online tools, including the use of bulletin board
software or other solutions to allow support staff real time access to the information being
shared in the EOC.
• Involve Security more in the exercise and ensure security procedures are fully tested.
• Consider acquiring a badge reader for access to the HR wing.
• Clarify individual roles and responsibilities, especially in areas of shared responsibility
between two or more agencies.
Lessons learned from the training exercises are captured immediately following the conclusion of the
exercise through a round -table debrief with the participants. In addition to the verbal feedback
several observers were asked to fill in a paper survey with their impressions of how things went. The
comments from the debrief session and the surveys were summarized and shared with the CEMPC.
Action items were added into the work plan for the CEMPC. There is currently no formal mechanism
to follow up with the participants to indicate how their issues have been solved or their suggestions
implemented or even provide them with a summary of all of the feedback.
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Recommendations:
Create an online feedback survey which can be filled out after the fact by all participants
including the CCG members, support staff and observers. This will save time in summarizing
the data as the results can be downloaded to Excel.
• Once the CEMPC has analyzed the feedback and created their work plan, circulate a copy of
the actions planned or taken to all participants and observers. This will serve to show them
that their ideas were heard and also to keep the topic of emergency management fresh in
their minds throughout the year.
During an emergency all CCG members and support staff are encouraged to keep personal logs of
information they receive and give, and decisions they make. These will form part of the official record
of how the emergency unfolded and what the City and partner agencies did to respond to it. The
information is critical in painting an accurate picture of the facts in the event of an inquiry, lawsuit, or
as part of an application for disaster funding. Therefore, it is imperative that personal logs be legible,
dated, page numbered, organized in time stamped order and marked with the authors name to
ensure that the logs can be properly analyzed and accounted for after the chaos of the emergency
abates.
As part of this audit the personal logs of the participants of the 2012 training exercise were examined
and analyzed based on the criteria listed above. It was found that all of the logs were dated and
organized in chronological order with the times of significant events noted. However, many were
lacking page numbers, the author's name or were illegible.
Recommendations:
• As part of the housekeeping messages mentioned above, reference to using the log books
and filling them in correctly should be made.
• The forms should be re- designed to include page numbers.
Maintenance
The overall emergency management program is constantly being added to and revised through
work of the CEMPC. Their agendas reflect work plan goals for the coming year to further
enhance and improve various aspects of the program based on current and highest priority
needs.
Recommendation:
• The CEMPC should put their minds to a longer range vision for the program and what
they would like to accomplish over the next 5 years. Included in this planning would be
the plans for training exercises as mentioned above. They could also include plans
relating to any of the 6 facets of emergency planning: governance, assessment,
planning, training and awareness, exercises and maintenance. This will help with
resource allocation should budget funding be needed for future activities.
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Conclusion
The positive results of this audit provide assurance that the citizens of Kitchener are in good
hands should a major emergency occur. The emergency program is well thought out, has a
comprehensive and well understood plan, and a committed team of individuals to execute the
plan. Many of the recommendations contained in this report are minor in nature. The most
critical recommendations focus on improving staff knowledge, level of training, and clearly
understanding roles and responsibilities to a detailed level. This also includes ensuring there
are trained backups for every role.
In addition, is important that the Fire Department provide dedicated administrative support to the
CEMPC in order to handle the workload associated with assembling the annual legislative
compliance documentation and supporting the annual exercise planning and execution.
Currently this is being done by a volunteer and is not sustainable.
By implementing these recommendations the CEMPC will be able to continue to improve on an
already excellent program.
A follow up audit will then be conducted not sooner than 1 year following the original audit to
determine the status of the recommendations and the impact they have had on the program.
Communication about the timing of this follow up audit will be provided at a later date, subject to
the internal audit work plan.
ALIGNMENT WITH CITY OF KITCHENER STRATEGIC PLAN:
Work falls within the Efficient and Effective Government plan foundation area of the Strategic
Plan. The goal of Internal Audit work is to protect the City's interests and assets through
— ensuring compliance with policy, procedures and legislation
— ensuring adequate controls are in place to protect our assets
— ensuring our operations are as efficient and effective as possible
This helps support the financial goal of long term financial stability and fiscal accountability to
our taxpayers.
FINANCIAL IMPLICATIONS:
While there are no immediate financial implications related to this report, several of the
recommendations contained herein may require funding should management adopt the
recommendations. The manner in which they are funded will be left to the discretion of the
management team and could include existing program funding, partnerships, or new operating
or capital budget requests. The items which may require additional funding include:
• part time administrative support
• provisioning of 72 -hour supply kits
• training
• full site and EOC simulation exercise
• collaboration software
• badge reader
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COMMUNITY ENGAGEMENT:
Members of the community have been informed of the results of this audit status report through
the posting of this report on the internet on June 20, 2013.
ACKNOWLEDGED BY: Dan Chapman, Deputy CAO, Finance and Corporate Services
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Second Quarter Audit
Committee
June 24, 2013
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2012 Audited Financial Statements
2nd Quarter Audit Status Update
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2012 Audited Financial
Statements
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2nd Quarter Audit Status
Report
FCS -13 -084
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Complete:
✓ Emergency Management Program
comprehensive audit
In progress:
❑ Operations Review
❑ The Aud and Arenas comprehensive audit
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ergency Management Program:
n
Audit Objective 1
• To assess whether the City's
Emergency Management Program
not only meets legislative
requirements but also provides a
framework which is understood
and easily put into action
• To assess the City's readiness and
capability to deal with large scale
emergencies
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Program Components
Tested
1. Governance
2. Assessment
3. Planning
4. Training and Awareness
5. Emergency Exercises
(Simulations)
6. Maintenance
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22 Staff interviews
5 external interviews
Participation in 2012 exercise as
observer
BEM and EOC training
• Internal &external literature review
• Tour of EOC
• Review of Internet /Intranet
content
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•Very positive results overall
• Emergency program is well
thought out
• Emergency plan is comprehensive
and well understood
• Have a team of committed
individuals to execute the program
• Most recommendations are minor
in nature and focus on continuous
improvement
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Main Findings &
0
Staff knowledge and training are
weak in some areas due to staff
turnover
— Ensure adequate training is provided
Not all roles and responsibilities
are understood
— Clarify roles and responsibilities
Not all roles have trained backups
— Identify and train backups
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Additional Findings &
Recommendations
Organized by Section
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Program complies with legislation
Senior management support and
adequate budget
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2-25
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2-26
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2-27
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2-28
Training Exercises con't
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2-29
rainin
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2012 Exercise
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2-30
Program is being continuously
improved
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requirements in many areas
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2 -31
LI
Emergency program is well
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managed
• Recommendations are minor and
focus on continuous improvement
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Main risk is in staff knowledge an
raining, mostly with new sta
2-32
Management response (from
CEMPC) due within 3 months
(Aug.2)
Follow up audit at a future
date ( +1 year)
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p w f
2-33
Questions?
yin
p w f
2-34