ORM Audit. ORM Audit Results. 1 General Safety

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1 ORM Audit Location Information Location Name Nicholls State Univ. - General Operations Location Code 4820 Mailing Address East First Street Mailing Address 2 City, State, ZIP Thibodaux, LA Safety Contact Brian Clausen Safety Contact Phone # (985) Safety Contact brian.clausen@nicholls.edu Location Mgr Contact Michael Davis Location Mgr Phone # (985) Location Mgr mike.davis@nicholls.edu Audit Information Reference # Audit Type Self-Audit Audit Date 09/02/2011 LP Officer Kimberly Ramer Audit Summary Results Score 98.33% Status Compliant. of Recs 5 ORM Audit Results 1 General Safety General Information Response Rec Number of Employees: 795 Number of Full Time Employees: 666 Number of Part Time Employees: Program Response Rec Is there a written general safety plan? Is the written general safety plan: Agency/Site Specific Does it contain a management policy statement from the department/agency head? Agency/Site Specific Has the program been presented to new employees during orientation and such action been documented? Is the program readily accessible to all employees? Are there written safety responsibilities? Have documented safety responsibilities been presented to all new employees initially during orientation and/or upon assignment to a position with different/additional safety responsibilities? Are there general safety rules? Have these rules been distributed (via safety meetings, postings, etc.) to all employees and such action documented? Are site/task specific safety rules required? Are there site/task specific safety rules? Have these rules been distributed (via meetings, posting, etc.) to all employees and such action documented? Safety Program Comments: Hard copies of the general safety program are located within all departments, as well as electronically on the Environmental Health & Safety Web-site. 1.2 Safety Meetings and Training Response Rec CLASS B: How many documented safety meetings have been conducted at this agency during the most 4+ recently completed audit/compliance Review period? CLASS B: Did the agency meet the 75% attendance requirement at every meeting during the audit period? CLASS B: Did the department and/or agency head (or his/her designee) meet the 100% attendance requirement during the audit period? Page 1 of 10

2 1.2.3-a Does the agency have a written policy that covers Drug-Free Workplace? Is the agency conducting mandatory, documented awareness/training on the basics of and the agency's policy on a Drug-Free Workplace within 1 year of hire? Is the agency conducting mandatory, documented awareness/training on a Drug-Free Workplace at least once every 5 years? b Does the agency have a written policy that covers Sexual Harassment? Is the agency conducting mandatory, documented awareness/training on the basics of and the agency's policy on Sexual Harassment within 1 year of hire? Is the agency conducting mandatory, documented awareness/training on Sexual Harassment at least once every 5 years? Is this audit being conducted for a Headquarters or a Field Office? Has the agency's designated loss prevention coordinator or other qualified position trained the field safety representative on the following: Field Office -----> Accident Investigation: -----> Inspections: -----> Safety Meetings: -----> Supervisor Responsibilities: Has the agency's designated loss prevention coordinator or other qualified position trained the field safety representatives on Job Safety Analyses (JSAs)? Has the agency's loss prevention coordinator and/or representatives attended documented training at least once every three (3) years on the ORM Loss Prevention Program? Is documented, specific training provided to all employees who must perform new tasks or operate new equipment, or whose safety performance is unsatisfactory? Safety Meetings and Training Comments: See training matrix located in Env. Health & Safety Office. 1.3 Inspections Response Rec Class B: How many potential inspections were there during the most recently completed audit/compliance 102 Review period? Class B: How many documented inspections were there during the most recently completed audit/compliance 102 Review period? Class B: What percentage of documented inspections were conducted during the most recently % completed audit/compliance Review period? Class B: Is an inspection documented? Class B: What type of documentation is used? Departmental/Generic Class B: Which topics does the inspection form address: -----> Building Safety: -----> Electrical Safety: -----> Emergency Equipment: -----> Fire Safety: -----> Office Safety: -----> Storage Methods: Class B: Is there a method in place for employees to notify management of workplace hazards? Class B: Is there a method in place for repair or corrective action of workplace hazards? Was there a State Fire Marshal's inspection completed at this agency during the most recently completed audit/compliance Review year? Were there any deficiencies found by the State Fire Marshal during these inspections? Page 2 of 10

3 Were the deficiencies corrected? 1.4 Incident/Accident Investigations Response Rec Do the agency's investigation procedures address the use of the DA2000/DA3000 or other equivalent form(s) regarding employee, visitor, and/or client situations? Do the agency's investigation procedures address bodily injury and/or property concerns? Has the agency had any accidents or incidents within the most recently concluded audit/compliance Review period? Is the agency using the DA2000/DA3000 or equivalent form for any accident or incident? Are all completed DA2000/DA3000 or equivalent form(s) from the prior fiscal year for all incidents/accidents available for review by the Loss Prevention Officer? Are Job Safety Analyses (JSAs) needed at this agency? Are JSAs developed for incident/accident trends, death, or change in job procedures or equipment? Is employee training on JSAs documented at least annually? Are the JSAs posted in the workplace in an area accessible to all employees? 1.6 Bloodborne Pathogens/First Aid Response Rec Does the agency have a written BBP program? Is the written BBP program: Both Does the agency BBP program address the following: -----> Exposure Determination: -----> Medical Evaluation for Affected Employees: -----> Methods of Compliance: -----> Awareness/Training: -----> Work Practice Controls: Employee Training on BBP Response Rec Is the agency conducting documented employee awareness/training on BBP for low risk employees within 1 year of hire? Is the agency conducting documented employee awareness on BBP for low risk employees at least once every 5 years thereafter? Are there any high-risk employees, as identified by the agency? Is the agency conducting documented employee training on BBP for high-risk employees within 90 days of hire? Is the agency conducting documented employee training on BBP for high-risk employees at least once every year? Are spill procedures in place? Are spill kits maintained? Does the agency have a written First Aid program for employees and visitors? Are First Aid kits maintained? Does the agency location meet any of the following criteria: *Working with night shifts or any minimal/partial crew shifts? *Employees working in remote/isolated locations? *The on-site medical facility is closed? Employee Training on BBP Comments: All new hires receive low risk training at orientation. First aid is provided by the University Health Services. After hour care is provided by Thibodaux Regional Hospital. Page 3 of 10

4 1.7 Emergency Preparedness Plan Response Rec Does the agency have a written emergency preparedness program? Is the written emergency preparedness program: Agency/Site Specific Does the plan address fire? Does the plan address natural disasters? Does the plan address proximity threats? Does the plan address terrorism? Are fire drills conducted at least once every 12 months (including space leased/outside of your agency's control)? Emergency Preparedness Plan Comments: Academic building fire drills have been completed since the last CR. Residence halls continue to be conducted once every semester. 1.8 Hazardous Materials Response Rec Has a documented assessment been conducted to determine if there are any hazardous materials at any agency location covered by this audit? Are hazardous materials present at any agency location covered by this audit? Does the agency have a written hazardous materials program? Is the written hazardous materials program: Agency/Site Specific Does the plan ensure that materials are handled properly? Does the plan ensure that materials are stored properly? Does the plan ensure that materials are disposed of properly? Does the plan ensure that Material Safety Data Sheets (MSDS) are available? Does the plan ensure that proper Personal Protective Equipment (PPE) is available? 2 Driver Safety 2.1 Program Response Rec Is there a written program that includes ALL of the following components? -----> Procedure for enrolling employees in the program: -----> Definition of high-risk drivers: -----> Procedure for identifying high-risk drivers: -----> Driver training: -----> Disciplinary action for employees identified as high-risk drivers: -----> Claims reporting: -----> Accident investigation: -----> Definition of State vehicles: Program Comments: The Director of safety monitors the program. 2.2 Inspection and Repair of State Owned Vehicles Response Rec Does the agency have any state-owned vehicles? How many potential vehicle inspections (# of vehilces X 12) were there in the most recently completed 648 audit/compliance Review period? How many documented vehicle inspections were conducted in the most recently completed audit/compliance 416 Review period? What percentage of your fleet was inspected? 60-79% Is documented corrective action taken on deficiencies noted on the checklist to prevent further damage or accidents? Is preventive maintenance performed and documented? Page 4 of 10

5 2.3 Training Response Rec Is documented defensive driving training provided for all agency employees authorized to drive on state business? Is initial training conducted within ninety (90) days of hire or entering the program via authorization on a DA2054 form? Is refresher training conducted once every three (3) years thereafter? Are all authorized employees who receive a conviction for a violation required to attend refresher training within ninety (90) days of conviction? 2.4 Records and Forms Response Rec Is there a signed and dated list of approved or unapproved drivers verified by the Official Driving Record (ODR) forms? Are Driver Authorization forms (DA 2054), that have been signed and dated annually, available for review? Are Official Driving Records (ODR), which have been reviewed annually, available for review? Have there been any vehicular accidents during the most recent one (1) year audit period? Has a Driver Accident Report Form (DA 2041) been completed for each accident? Have all of the DA 2041 forms been faxed/ ed within forty-eight (48) hours to the Claims Unit? 3 Bonds, Crime & Property 3.1 Program Response Rec Is there a written program that addresses the prevention of property damage and/or loss? Are there procedures in place to address separation of duties? Are there procedures in place to address controlling inventories? Are there procedures in place to address purchasing procedures? Are there procedures in place to address reporting losses/damages? Are there procedures in place to address investigating losses/damages? Are there procedures in place to address timely reporting of losses to the correct ORM claims unit? Are there procedures in place to address handling negotiable items? Are there procedures in place to address securing vaults/safes? Is someone assigned the responsibility for keeping the program current? 3.2 Employee Responsibility Response Rec Does the agency program outline employee responsibility? Have only authorized employees been assigned to duties covered under the program? Are employees receiving documented training in their job duties per the program? 3.3 Security Response Rec Is there a comprehensive written security policy that includes but is not limited to procedures that address limited, controlled access for authorized individuals to Page 5 of 10

6 buildings? Is there a comprehensive written security policy that includes, but is not limited to procedures that address monitoring/controlling visitor access? Is there a comprehensive written security policy that includes but is not limited to procedures that address securing all entrances and exits? Is there a comprehensive written security policy that includes but is not limited to procedures that address limiting access to data on personal computers? Security Comments: Nicholls has a fully commissioned police department for security. 3.4 Key Control Response Rec Is there a key/access card control policy in place? Does key control policy include the following: -----> A key/card log? -----> Procedures to change locks/codes? -----> Methods for issuing, returning, and accounting for lost/stolen keys/cards? -----> Specifying employee responsibility/procedures for handling keys/cards? 4 Equipment Mgmt General Information Response Rec 4.1 Does the agency have any mechanical and/or electrical [i.e., systems/equipment that are integral to the operation of the building and/or are an affixed (i.e., hardwired and/or plumbed) part of buildings/structures] equipment? Program Response Rec Is there a written equipment management program? Is the written equipment management program: Departmental/Generic Does it address mechanical equipment? Does it address electrical equipment? Is there a current, specific inventory of ALL applicable program equipment? Are there preventive maintenance procedures for inventoried equipment? Is there a written preventive maintenance schedule for mechanical equipment? Is there a written preventive maintenance schedule for electrical equipment? Is preventive maintenance documentation being maintained for mechanical equipment? Is preventive maintenance documentation being maintained for electrical equipment? Does the program include testing procedures for mechanical equipment? Does the program include testing procedures for electrical equipment? Are maintenance and/or other designated employees trained on the written Equipment Management program? Is formal and/or on-the-job training for the operation of inventoried equipment documented? Is formal and/or on-the-job training for the operation of testing equipment documented? Is formal and/or on-the-job training for assigned maintenance duties documented? Program Comments: Nicholls State utilizes the ORM manual as its guide. Documentation of all inventory is maintained on an electronic version and located at Physical Plant Personal Protective Equipment (PPE) Response Rec Page 6 of 10

7 Has a documented assessment been conducted to determine if the use of any Personal Protective Equipment is required? a Is Personal Protective Equipment required? Are there written procedures that address the: procurement, use, maintenance, and disposal of PPE? Work Order System Response Rec Are there written work order procedures for the following areas: -----> Scheduled preventive maintenance: -----> Reported problems: Are all repairs documented? Are employees aware of the written procedures for reporting problems via the work order system? Work Order System Comments: Scheduled preventative maintenance is being conducted, but not part of the work order procedure Lockout/Tagout (LO/TO) Response Rec Will any LO/TO be performed by agency personnel? Does the agency have a written LO/TO program? For LO/TO performed by agency personnel, is there documented training for the following: -----> Authorized Employees: -----> Affected Employees: Will any LO/TO be performed by a contractor? Does the contractor have their own written LO/TO program? Are proper LO/TO devices available? Lockout/Tagout Comments: Training documentation located at safety Office Boilers Response Rec Does the agency have boilers that meet the criteria which mandate an inspection? Are current certificates posted at/near equipment? Have all items cited in the inspection report been corrected and documented? Elevators & Fire Service Key/Equipment Room Response Rec Does the agency have elevators? Are current elevator certificates available? Have ALL code violations been corrected and documented? Are there written procedures outlining availability of the fire service key? Has the fire service key been provided to the designated employee? Is the fire service key provided to the local fire department or readily accessible upon their arrival? Elevators & Fire Service Key/Equipment Room Comments: Fire service key is located at the maintenance facility and is readily available Confined Space Response Rec Has a documented assessment been performed to determine if confined spaces exist? Were any confined spaces identified? Do the identified confined spaces require a permit? Is ALL confined space entry work contracted out? Page 7 of 10

8 Is there a written confined space entry program that covers training? Is there a written confined space entry program that covers PPE? Is there a written confined space entry program that covers Rescue? Is there a written confined space entry program that covers Environmental Testing? Is there a written confined space entry program that covers Permits? Is all required confined space equipment available? Is training provided to applicable employees on Equipment? Is training provided to applicable employees on PPE? Is training provided to applicable employees on Rescue? Is training provided to applicable employees on Environmental Testing? Is training provided to applicable employees on Permits? Does the contractor have their own written confined space program? Confined Space Comments: t Applicable t Applicable Rescue only required for permit confined spaces. permit confined spaces identified, specific training will be conducted prior to entry of any confined space. General awareness training on confined spaces has been provided and documented. 5 Water Vessel General Information Response Rec 5.1 Does the agency have any state-owned water vessels (e.g., boats, ferries, airboats)? Program Response Rec Is there a written program that includes ALL of the following components? -----> Procedure for authorizing employees in the program: -----> Definition of high-risk operators: -----> Determination of high-risk operators: -----> Operator training: -----> Disciplinary action for employees identified as high-risk operators: -----> Claims reporting: -----> Accident investigation: Is someone assigned to monitor the program? Inspections and Repairs Response Rec Were any deficiencies found during the inspection? Have corrective actions been taken for deficiencies found during the inspection? Have the corrective actions been documented? Are there any vessels that are twenty-six (26) feet or longer? Is periodic, preventive maintenance, per the manufacturer's recommendations, performed and documented? Inspections and Repairs Comments: Regular scheduled maintenance of the three small boats are taken to a local boat mechanic for service/repairs Training Response Rec Is initial training "Boat Louisiana" conducted before authorization to drive is granted and/or within ninety (90) days of hire or the employee(s) entering the program? Page 8 of 10

9 Is a refresher course conducted once every three (3) years thereafter? Are all authorized employees who receive a conviction for a violation required to retake the "Boat Louisiana" or other ORM recognized course within ninety (90) days of conviction? Records and Forms Response Rec Is there a signed and dated list of approved operators indicating annual verification of the operator records? Are the Vessel Authorization/Operator History forms (DA 2066) signed and dated annually? Have there been any water vessel accidents, in a commercial vessel over navigable waters, during the most recent three (3) year audit period? Have there been any non-commercial vessels involved in an accident in any waters? 6 Flight Operations General Information Response Rec 6.1 Does the agency have any state aircraft? Page 9 of 10

10 Recommendations Location: 906 East First Street, Thibodaux, LA Fleet Inspections Per the manual, supervisors shall see that all vehicles provided to employees are in safe operating condition, including the use of a monthly checklist Claims Reporting Provide verification that the DA 2041 was forwarded by fax or to the Claims Unit, within forty-eight (48) business hours of the vehicle incident/accident and maintain documentation for the audit Written Work Order Procedures - Preventive Maintenance Ensure there are written work order procedures for scheduled preventive maintenance Confined Space - Rescue Provide a written confined space entry program that covers Rescue Confined Space - Rescue Training Provide documented training to applicable employees on Rescue equipment and procedures. Page 10 of 10