United States Environmental Protection Agency Superfund Office of Solid Waste and Emergency Response Publication 9200.8-05 EP A540/R-94/014 PB94-963232 March 1994 Audit Management Process Reference Guide ------- EPA/540//R-94/014 Directive: 9200.8-05 March 1994 Audit Management Process Reference Guide This document is a draft and should not be quoted or cited. It has not yet been subject to EPA policy review. Office of Emergency and Remedial Response U.S. Environmental Protection Agency Washington, DC 20460 ------- Table of Contents I. Introduction 1 II. Participants 2 a. General Accounting Office 2 b. Office of the Inspector General 2 c. Audit Resolution Board and Audit Review Group 3 d. Agency Roles and Responsibilities 4 HI. Ethics 5 IV. Types of Audits 6 a. Performance Audits 6 b. Financial and Compliance Audits 6 c. Other Types of Reviews 7 d. Other Related Documents 7 V. Importance of Timely Response 9 VI. The GAO and OIG Audit Process 10 a. Phase One of the Audit Process 11 b. Phase Two of the Audit Process 13 c. Phase Three of the Audit Process 15 d. Phase Four of the Audit Process 23 Appendix A: Glossary of Audit Terms A-1 ------- Acronyms AA Assistant Administrator AFC Audit Follow-up Coordinator ARB Audit Resolution Board ARG Audit Review Group EPA Environmental Protection Agency FMFIA Federal Managers' Financial Integrity Act GAO General Accounting Office HQ Headquarters IG Inspector General 10 Immediate Office MATS Management Audit Tracking System MTS Milestone Tracking System OARM Office of Administration and Resources OASYS Office Automation System OERR Office of Emergency and Remedial Response OIG Office of Inspector General OMB Office of Management and Budget OPM Office of Program Management OSWER Office of Solid Waste and Emergency Response POD Priority Office Director RA Regional Administrator RMD Resource Management Division SRIS Superfund Report Information System * \ i ------- I. Introduction Audits are a critical way to measure how well EPA is implementing its environmental programs and carrying out its management responsibilities. Federal law requires Executive and Federal Branch agencies to institute programs designed to respond to and follow-up on audits issued by the Agency's Office of Inspector General (OIG) and the General Accounting Office (GAO), the two main bodies which audit EPA programs and activities. The audit management process is comprised of three main activities; cooperating with auditors to provide information, responding to the audits, and implementing audit recommendations to correct deficiencies found during the investigation. The Office of Management and Budget (OMB) issued Circular A-50, "Audit Follow-up" in September, 1982, which provides policies and procedures for Executive Branch agencies when reviewing, responding to, and implementing recommendations of audit reports. In order to ensure compliance with OMB Circular A-50 and to clarify roles and responsibilities of participants in audit response and follow-up, EPA (Resources Management Division, Office of Comptroller) issued EPA Order 2750 "Management of EPA Audit Reports and Follow-up Actions" and EPA Order 2780. IB "GAO Audits: Agency Relationships with GAO and Responsibilities for Follow-up Actions" in 1984. This reference guide is designed to describe the audit management process, relevant terms, roles and responsibilities of participants, and helpful hints and tools for full compliance. General language is used to discuss the overall process within EPA, but this guide is primarily geared toward Office of Solid Waste and Emergency Response (OSWER) and Office of Emergency and Remedial Response (OERR) managers and staff. 1 ------- II. Participants Within the Federal Government, two officesthe General Accounting Office (GAO) and the Office of the Inspector General (OIG)are authorized to conduct audits of EPA. Each office conducts numerous performance and financial audits to promote efficient and effective operations within Agency programs. Further, EPA has delineated roles and responsibilities for key individuals responsible for audit management, including audit arbitrators and Agency audit officials. These participants are described in more detail in this section. a. General Accounting Office The GAO is the investigative arm of Congress responsible for auditing and evaluating programs, activities, and financial operations of the Executive Branch. The Budget and Accounting Act of 1921 and the Accounting and Auditory Act of 1950 authorize GAO to conduct audits and investigations of Executive Branch departments and agencies solely at the request of individual members of the House and Senate. Duties and Responsibilities GAO audits are independent examinations of the effectiveness in which Executive Branch departments and agencies carry out their mandated programs and financial responsibilities. GAO conducts examinations to assess the implementation and effectiveness of Executive Branch programs for compliance with statutory objectives. The GAO also prepares and delivers Congressional testimonies of its findings, recommendations, and the corrective actions taken by audited agencies and departments. GAO provides findings and conclusions, then recommends corrective actions to Congress and Agency officials in written reports. b. Office of the Inspector General Each Executive Branch Agency has an OIG. The OIG is responsible for conducting independent audits and investigations of Agencies' programs and activities. In addition, the OIG oversees the work of non-Federal auditors (special interest groups) performed in connection with Federal Programs. The Inspector General (IG) Act of 1978 provides statutory authority to establish OIGs in most departments and major agencies of the Executive Branch. Each IG is a political appointee, primarily accountable to the President, with very little accountability to the head of the department or agency. The EPA Administrator established and consolidated audit and investigative operations into an independent OIG in 1980. The IG Act Amendments of 1988 mandated new semiannual reporting requirements to Congress for department and agency management. 2 ------- Duties and Responsibilities The OIG for EPA conducts, supervises, and coordinates audits and investigations relating to programs and operations of the Agency. The OIG also recommends policies to promote economy, efficiency, and effectiveness, and to detect and prevent waste, fraud, and abuse. Serious or potentially serious problems of waste, fraud, and abuse are reported under the Federal Managers' Financial Integrity Act (FMFIA) (see EPA Publication 9200.9-01, "FMFIA: A Manager's Quick-Reference Guide to the Federal Managers' Financial Integrity Act"). Finally, the OIG keeps the EPA Administrator and Congress fully informed of problems related to the operation of programs, and the necessity for and progress of corrective actions. c. Audit Resolution Board and Audit Review Group When proposed measures to correct an identified weakness are not agreed upon by the OIG and the audited program, they are referred to the Audit Resolution Board (ARB) and the Audit Review Group (ARG) for review. The ARB reviews OIG audit cases in which resolution has been disputed or delayed, and decides the final Agency position for resolving such audits. The Board consists of the Assistant Administrator (AA) for Administration and Resources Management (OARM), the EPA General Counsel, and a Regional Administrator serving a one-year, rotating term. The ARG serves as the ARB's advisory staff by analyzing the issues, obtaining additional information, and developing recommendations to the board for cases under review. ARG members include of the Senior Staff Designee of the AA/OARM for audit resolution, the Associate General Council for Grants, Contracts, and General Law, and a Deputy Regional Administrator serving a one-year rotating term. The Assistant Inspector General for Audit, the Office Director of the audited program, and the Director of the Office of Administration serve in an advisory role to the group. The Office of the Assistant IG for Audit refers cases for review by transmitting to the ARB, ARG, and person assigned for all activities associated with a specific audit (Action Official) the following documents: A statement of the issues and the determinations requested Background information on the audit A brief description of the auditor's and the Action Official's positions. Once the ARG has analyzed the case and made recommendations, the ARB convenes a meeting to decide the case. All ARB decisions are final. 3 ------- d. Agency Roles and Responsibilities Several officials within OSWER and OERR are designated audit management roles and responsibilities. Figure 1 identifies agency officials who conduct audit management functions, their corresponding audit management title, and their responsibilities in the audit management process. Audit Roles Agency Audit Follow-up Official AA/OARM Jonathan Cannon Agency Audit Follow-up Coordinator (AFC) Director RMD, and Steve Tiber, RMD Audit Management Officials RA or ARA AA or Office Director Elliot Laws, Henry Longest Action Officials RA or ARA AA or Office Director Elliot Laws, Henry Longest Audit Follow-up Coordinators OSWER AFCs Laurie May Johnsie Webster Charlene Dunn OERR AFC Sharon Hallinan Audit Responsibilities Responsibilities include: Resolving and implementing corrective actions for audits agency-wide Informing the EPA Administrator of significant issues. The Agency AFC responsibilities include: Acting as liaison between audit agencies and EPA staff Providing an early warning of planned audits to HQ and the Regions Preparing reports on audit resolution requested by agency management or external parties. Responsibilities may be delegated to Office Directors from the AA. The Audit Management Official is responsible for managing the office's overall audit responsibilities, including: Ensuring all managers and staff understand the audit process Directing the timely and effective resolution of audits Ensuring the completion of all corrective actions proposed in response to a specific audit. Responsibilities may be delegated to Office Directors from the AA. The Action Official is responsible for all activities associated with a specific audit, including: Responding on behalf of the Agency to draft and final reports Ensuring the completion of all corrective actions proposed in response to a specific audit. The OSWER AFC responsibilities include: Overseeing overall audit management activities with OSWER Tracking the implementation of audit recommendations Serving as point of contact between OSWER, OIG, and GAO Tracking the progress of audits Tracking the progress of corrective action implementation Preparing monthly OSWER audit activity reports. The OERR AFC responsibilities include: Coordinating OERR audit responses Training OERR staff in audit management Serving as audit liaison with OSWER and external offices. Figure 1: Agency Audits Roles and Responsibilities 4 ------- III. Ethics GAO and OIG audits address a program's adherence to applicable laws and regulations, assess vulnerabilities of government resources, and identify weaknesses in program controls and operations which must be corrected. According to the Agency directive "6500: Functions and Activities of the Office of the Inspector General," the OIG may investigate alleged violations of the government- wide regulations on ethics and standards of conduct. This directive requires all employees to promptly report instances of, and information on, any known or suspected violation of laws, rules or regulations, or mismanagement; gross waste of funds; abuse of authority; or substantial and specific danger to public health and safety. These investigations result in an official audit report. In addition, the results of these investigations may be included in OIG's semiannual report to Congress. The OIG confidential hotline, listed below, was established for this purpose: 1-800-424-4000 or (202) 260-4977 As part of the Ethics guidelines, managers are responsible for: Establishing, maintaining, and improving controls over government resources within their areas of responsibility Identifying and correcting problem areas prior to GAO and OIG audits Ensuring all staff are aware of their responsibilities by attending training, working closely with the FMFIA/Audit follow-up Coordinator, and maintaining open communication with management. Ethics in the workplace depends upon an individual's integrity, honesty, and compliance with Federal laws and Agency policy. 5 ------- IV. Types of Audits GAO and OIG conduct several types of audits to measure EPA's effectiveness in implementing its programs and carrying out its responsibilities. In broad terms, these audits can be identified in one of two categories: Performance Audits, or Financial and Compliance Audits. a. Performance Audits Performance Audits of EPA programs and operations are conducted to evaluate the economy, efficiency, and effectiveness of Agency activities and to determine whether the Agency is meeting or achieving its objectives. Following is a description of two types of Performance Audits: Program Audits determine the extent to which the desired results or benefits established by Congress or other authorizing bodies are being achieved; the effectiveness of organizations, programs, activities, or functions; and whether the Agency has complied with laws and regulations applicable to a program. Economy and Efficiency Audits determine whether the Agency is acquiring, protecting, and using its resources economically and efficiently; ensure that the Agency is complying with laws and regulations concerning economy and efficiency; and identify the causes of found inefficient or uneconomical practices. b. Financial and Compliance Audits Financial and compliance audits are conducted to determine how effectively EPA is complying with the statutes, regulations, or agreements under which Federal funds and Superfund monies are disbursed. A description of the two types of Financial and Compliance Audits follows: Financial Statement Audits determine whether the program has complied with laws and regulations for those transactions and events that may have a material effect on financial statements; and whether financial statements of an audited program present fairly its financial position in accordance with generally accepted accounting principles. Financial-Related Audits determine whether financial reports and related items, such as elements, accounts, or funds, are accurately presented; whether financial information is presented in accordance with established or stated criteria; and whether the entity has adhered to specific financial compliance requirements. 6 ------- Internal versus External Audits Audits can be categorized as either internal or external audits as described below: Internal (and Management) Audits are independent reviews of programs and operations managed and administered internally by EPA Headquarters and the Regions. External Audits are independent reviews of the records and performance of the relevant programs and operations of external entities that are financially and/or programmatically associated with EPA. A performance audit (also called a program audit) can be further described as either an internal or external audit. The same is true of financial and compliance audits. c. Other Types of Reviews There are several other types of reviews and evaluations that represent audits for special purposes, limited scope, and timely turnaround. Some of the more frequently conducted reviews are described below: Special Reviews: Annual audits typically have statutory mandates requiring their conduct. However, auditing agencies may decide to investigate related topics as part of their annual efforts or expand the scope of the audit. These additional topics and expansions become identified as special reviews with their own published reports associated with the annual audit. Annual unannounced audits are conducted at selected removal and remedial sites. The audits review all activities at each site for performance, financial state, and compliance. Forewarning of selection for review is not provided to the chosen sites. These reviews revisit previously audited subject matter to evaluate the status of conditions and improvement efforts since the initial audit was conducted. Further recommendations may result from a follow-up review. d. Other Related Documents In addition to the different types of performance and financial and compliance audits, EPA managers should be familiar with the following audit-related documents: Fact Sheet: A short summary of a GAO follow-up study that revisits a previous audit report, usually without a complete investigation. Unannounced Site Visits: Follow-up Review: 7 ------- Position Papers: An opportunity for Agency managers to comment on the preliminary findings of an OIG audit. Position papers do not contain recommendations, and are typically issued prior to the release of the audit draft report. Testimony: The witness statements of GAO, EPA, or other expert officials presented at a Congressional hearing on a specific topic. The testimony is recorded in a report. Testimonies may move Congress to initiate an audit to more thoroughly investigate the particular issue. Capping Report: A capping report is not actually an audit. It is an effort to consolidate the results of two or more related audits under one final report. For example, separate audits of the procurement practices of soil sampling services may have been conducted in three Regions over several years. A capping report may be issued to summarize the findings and recommendations for all three audits. 8 ------- V. The Importance of Timely Response The GAO and OIG publish numerous reports throughout the year for which the Agency is provided an opportunity to comment in both draft and final versions. EPA defines its responsibilities for implementing the auditor's recommendations in its comments to the draft report. If EPA fails to provide comments to draft reports in a timely fashion, the final report is prepared without Agency input regarding the findings and recommendations. As a result, the final report may contain factual errors and EPA managers may be held accountable for implementing recommendations for which they are not actually responsible. Agency comments to draft and final reports are required and are provided differently for each audit agency. EPA response requirements for GAO and OIG are described below. Responding to OIG Audits EPA has 30 days from the release date to respond to OIG draft reports. The Action Official for the specific audit coordinates the Agency's written response. If EPA fails to provide written comments to the OIG draft report within 30 days, the final report is prepared without Agency input regarding audit findings and recommendations. EPA has 90 days to respond to OIG final reports. Responding to GAO Audits GAO's policy is to obtain comments to draft reports, however, the Congressman requesting the report may ask GAO not to accept written comments from EPA. In this case, Agency comments are transmitted informally at the Exit Conference. Again, it is important that the Agency provide comments to the GAO draft report, or the final report will be prepared without Agency input regarding the factual content of the report. GAO reports are available to the public, therefore, it is essential that these reports are free of factual error. Once GAO releases a final report, the audit initiator (Congressman or Senator) may hold the report for up to 30 days before it is released to EPA. After this 30- day period, EPA has 30 days in which to respond to the final. The initiator may decide to release the report within the first 30 days, thus giving EPA up to 60 days to respond to the final report. Response time varies for GAO reports, and the time allowed for Division comments is typically less than two weeks. It is critical that Agency responses to GAO final reports are timely. Specifically, GAO testifies to Congress that the Agency did not provide a response to a particular audit if the response was late. To meet audit responsibilities, Agency officials should monitor all audits and be present at all meetings with GAO and OIG auditors to discuss audit issues. If responses are submitted late, the Agency forfeits its input opportunity and is responsible for all findings and recommendations as recorded in the audit report. 9 ------- VI. The GAO and OIG Audit Process This section describes the audit process through a discussion of the nine discrete events which comprise the audit process. To further order this discussion, the audit process has been divided into four phases. Figure 2 illustrates the sequence of events within these phases. The following pages describe each of these activities in detail. Early Warning and Notification Entrance Conference Survey Phase Draft Report Response Requirement Exit Conference Final Report Response Requirement Audit Follow-up and Reporting Figure 2: The Four Phases of the GAO and OIG Audit Process The first phase describes activities that precede the release of a draft report. The second phase focuses on activities as a result from the release of the draft report, including a discussion of response requirements for draft GAO and OIG reports. The third phase outlines activities associated with the release of a final report, including a discussion of response requirements for final GAO and OIG reports and the correct format and routing of a response. The final phase summarizes the implementation of corrective actions during the follow-up process, and the tracking and reporting of these activities. 10 ------- a. Phase One of the Audit Process Early Warning and Notification Entrance Conference Survey Phase Draft Report Response Requirement Exit Conference Final Report Response Requirement Audit Follow-up and Reporting Figure 3: The First Phase of the GAO and OIG Audit Process Early Warning and Notification Early Warning and Notification allows EPA to prepare for the demands of upcoming audits. EPA's Audit Follow-up Coordinators (AFCs) provide warning of upcoming audits by obtaining and distributing audit planning information from GAO and OIG. Each year, the OIG produces an Annual Audit Plan describing all recurring and planned special audits to be conducted. In addition, the GAO Audit Liaison informs program offices of audits that may be conducted by GAO during the fiscal year. Advance notification of an audit's focus allows OERR Division staff to begin reviewing and preparing records for these audits, and helps to ensure a timely Agency response. SRIS is OERR's automated tracking system for Superfund related audits. When the Agency is made aware of a new audit, SRIS is used to begin tracking the audit. Major activities or events and Agency responsibilities are recorded throughout the audit's life cycle. Upon completion, SRIS is used to track the corrective actions that OERR is responsible for implementing. SRIS is a valuable resource for EPA managers with audit response and follow-up responsibilities. For more information about SRIS, please refer to the SRIS System Overview and Users' Guide (EPA 9200.8-05-1). Entrance Conference An Entrance Conference is a meeting held to officially begin an audit. At this conference, auditors explain the purpose, scope, and objectives of the audit and the timetable for completing the audit. The auditors also request access to pertinent records and information, and the names of key program contacts. 11 ------- The conference is chaired by the audit agency and is attended by key officials of the activity being audited. In addition to the Action Official and Auditors from the audit agency, officials from the Office of Administration and Resources Management are invited to attend all Headquarters Entrance Conferences. Survey Phase The Survey Phase of an audit follows the Entrance Conference. During this phase, auditors investigate the status of a program or activity by collecting data, performing analyses, and conducting interviews. In order to facilitate this process, auditors have access to, and the right to examine, all books, documents, papers, and records of the Agency. The only exceptions are records and information prohibited from release by regulation, statute, or executive order. Throughout the Survey Phase, auditors may request additional information to support their investigation. This information may include written explanations of Agency practices, justifications for decisions or special statistical summarizations, interviews with program staff, and copies of internal files or reports. Specifically, EPA is required by statute to provide information regarding its duties, activities, organization, financial transactions, and methods of business. If an Agency official considers it advisable to withhold specific records or information requested by an audit representative, the official should immediately notify the OSWER AFC. The OSWER AFC and the agency official will determine if access should be granted or denied. 12 ------- b. Phase Two of the Audit Process Early Warning and Notification Entrance Conference Survey Phase Draft Report Response Requirement Exit Conference Final Report Response Requirement Audit Follow-up and Reporting Figure 4: The Second Phase of the GAO and OIG Audit Process Draft Report and Response Requirement Following the Survey Phase, auditors prepare draft results of their investigations and analyses, and address copies of these draft reports to the Agency AFC and the OSWER AFC. The OSWER AFC distributes them to the Action Official within the appropriate program offices, where the report is reviewed for accuracy and comments developed. GAO and OIG prepare different types of draft reports, requiring different types of Agency responses. The format and Agency response requirements of GAO and OIG draft reports are described in the following pages. GAO Draft Report The GAO draft report consists of only two basic sections. The first section, the Preface, provides a brief overview of the background and objective of the audit. A discussion of each issue and its principal findings follow the Preface. Unlike an OIG final report, no conclusions or recommendations are included in the draft report. Only facts are presented in this version. GAO Response Requirements The relevant OERR staff and managers are given an opportunity to review the draft report for factual accuracy. The draft report is made available the day of the exit conference. Upon review, the Agency is required to return the draft report. These reports have been provided to the Agency in limited quantity, with each report numbered to ensure their return to GAO. Congressional requirements typically prevent the Action 13 ------- Official from providing formal written comments. In such cases, only informal oral comments may be used to address the accuracy of the findings contained in the draft report. Because GAO is not allowed to accept written responses to the draft report, it is not necessary to have a formal time period within which EPA must respond. Agency comments to draft GAO reports are most often communicated to auditors within a few days of the receipt of the report (see Exit Conference). In the infrequent occasion in which Congressional requirements allow written comments to the draft by EPA, the Agency may have up to 30 days to provide written comments. 01G Draft Report The OIG draft report more closely follows a final report structure than does its GAO counterpart. The OIG draft report is divided into two sections, the executive summary and the main body of the report. The executive summary is a synopsis of the report, including brief discussions of the purpose, background, and results of the audit. The main body of the report includes a table of contents, an introduction (purpose and background), and a detailed chapter for each finding. Unlike GAO's version, the OIG draft report includes conclusions and recommendations with each finding. In addition, recommendations can be addressed to an Assistant Administrator, Office Director, or even a specific division or branch. OIG Response Requirements Unlike responses to GAO draft reports, Agency comments to OIG draft reports are formally solicited. EPA has more latitude in the types of written comments they may provide to OIG than to GAO. Agency comments should address the factual accuracy of the report findings, provide response to recommendations and even address the responsibility assignment of recommendations. OIG must receive EPA's comments within 30 days of the Agency's receipt of the draft report. If EPA fails to provide written comments within 30 days, OIG will prepare the final report without Agency input regarding findings, conclusions, and recommendations. The format for a response to a draft OIG report is identical to the final response. Examples of response formats are included later in this section. For both GAO and OIG reports, the Agency loses the opportunity to influence the content of the final report if comments are not provided in a timely mariner. As a result, the final report may contain factual errors or EPA managers may be held accountable for implementing recommendations for which they are not actually responsible. For a more detailed discussion of the importance of a timely response, please refer to Section V. Exit Conference Scheduled soon after the release of the draft report, the Exit Conference is generally the last opportunity for all the audit participants to have a face-to-face discussion 14 ------- concerning the draft report The purpose of these discussions is for all audit participants to have an understanding of the scope and contents of the draft report. However, the nature of these discussions differs between GAO and OIG Exit Conferences. These differences are described in the following pages. GAO Exit Conference As mentioned in the previous section, GAO does not typically solicit written comments to the draft report. Oral comments are addressed at the Exit Conference. In addition, only comments addressing the factual accuracy of the draft report are accepted and discussed. OIG Exit Conference Discussions at an OIG Exit Conference are more extensive. Like the official written comments, EPA's discussions with the OIG may question or disagree with any aspect of the contents of the draft report. As a result, the OIG Exit Conference also serves to allow EPA and OIG to resolve any major disagreements concerning the draft report. Early Warning and Notification Entrance Conference Survey Phase Draft Report Response Requirement Exit Conference Final Report Response Requirement Audit Follow-up and Reporting Figure 5: The Third Phase of the GAO and OIG Audit Process c. Phase Three of the Audit Process Final Report Once comments to the draft report are received (written or oral), and the Exit Conference has been held, the auditors publish the final report. Both GAO and OIG Final Reports include an Executive Summary, main body, and appendices. Both reports include findings, conclusions, and recommendations in the main body. The reports differ in that GAO Final Reports typically do not include a written discussion of the Agency's 15 ------- comments to the draft report (unless special permission was granted allowing EPA to provide formal comments to the draft report). The Agency comments to the draft report are separated into specific comments addressing specific findings, conclusions, or recommendations. In the OIG final report, OIG includes a summary of the relevant Agency comments at the end of each related findings chapter. In addition, OIG Final Reports include the written Agency comments to the draft report in original form as part of the appendix. This allows agreements and disagreements to be officially recorded. The final report (GAO or OIG) is an official document. The report is binding insofar as the Action Official is responsible for ensuring that the report recommendations are implemented in a timely and effective manner. Response Requirement Response preparation requires EPA coordination at several levels. Coordination begins within OSWER. The OSWER AFC receives and directs audit reports to the OERR AFC. The OERR AFC notifies the appropriate branch or division of its response requirements. If more than one branch or division is responsible, the OERR AFC coordinates their responses and forwards them to the OERR front office for approval. All responses with Regional implications require Regional review and concurrence prior to their submission to the OSWER AFC. For GAO final reports, the GAO Audit Liaison is delegated the responsibility of coordinating the Agency response. Once the response is prepared, a final review (Red Border Review) of the response is conducted by all relevant Agency staff and managers for final concurrence. The AA/OARM is ultimately responsible for the preparation of the Agency response to a GAO final report. Once the Agency response receives final approval, it is formally transmitted to the audit agency. Figure 6 depicts the six-step process OSWER/OERR uses in responding to an audit. 16 ------- OERR AFC OERR AFC/cc AA's Office/ OSWER AFC Director's Office/OERR AA's Office/ OSWER AFC Responsible Division(s) All audit reports are directed to the AA/OSWER and the OSWER AFC. The OSWER AFC attaches a transmittal memo signed by the Director of OSWER Organizational Management and Integrity Staff to each report and forwards the original and copies to the OERR AFC. OERR AFC identifies responsible divisions, assigns Office Automation System (OASYS) Priority, Office Director (POD) numbers for tracking, attaches POD Control Sheets to each report, then distributes the report to the divisions responsible for contributing to the Agency's response. Division Directors oversee response preparation. Division staff prepare responses that address the findings and recommendations within the report. The divisions establish achievable corrective actions (milestones) and include them in the final response. OERR AFC coordinates division responses, then reviews responses for adequacy and compliance with audit response guidelines (see sample response form). A copy of the response is forwarded to the Director, OERR for review. The Director, OERR reviews the audit report and response for responsiveness and concurrence. Audit reports and responses are then returned to the OERR AFC for forwarding to the OSWER AFC and AA's office. The OSWER AFC reviews the report and response. Responses to GAO audit reports include a Red Border Review of the response. The response is approved and signed by the AA or Deputy AA. Final signature copy of the report and response is returned to the audit agency. Figure 6: OSWERJOERR Audit Response Process 17 ------- Format of Audit Responses Audit responses should follow a standard format which includes a header identifying the relevant report, the response preparer, and the response receiver. In final form, the response to a GAO final report is addressed from the AA/OARM to GAO. The response to an OIG final report is addressed from the Action Official (AA/OSWER for OSWER related audits) and addressed to OIG. The main text of the response letter includes each recommendation, the response, and a relevant workplan of milestones to implement the recommendation. Milestones included in the response should be achievable as determined by the designated Action Official. All milestones will be tracked until completed, therefore, it is essential to weigh carefully realistic comments to milestones and specific implementation dates. Divisions are encouraged to contact the OERR AFC if further assistance is needed. The audit response should restate the recommendation, indicate the page number of the report where the recommendation is found, and be followed by a response including completed and pending milestones. Always include page numbers, starting with page two, and left-justify all text. If OERR is the sole responder to the report, the response memorandum should be addressed to the audit originator, from the Assistant Administrator. For comments prepared for the OIG, use the format shown in Figure 7. An example of a response prepared for GAO is illustrated in Figure 8. 18 ------- MEMORANDUM Subject: OIG Final Audit Report on "Program Review, EISF61-15,5001" From: Elliott P. Laws Assistant Administrator To: Audit Originator, Title Office of Inspector General The purpose of this memorandum is to transmit our response to the recommendations contained in the subject audit report. Recommendation to the AA. QSWER (page 8): Identify the universe of regulated facilities and prioritize inspections to ensure that facilities which pose the greatest threat to the environment are being inspected. QSWER Response: We accept this recommendation, and the AA, OSWER, will direct the development of a tank inventory and investigate the use of local inspector resources. Milestones: Completed Identified and contacted qualified inspectors through professional trade group during the first quarter of 1992. 7/30/92 Develop an approach for identifying and collecting tank inventory data for prioritized inspections. Thank you for the opportunity to comment on this subject report. If you have any questions, please call Charlene Dunn, OSWER Audit Follow-up Coordinator, at (202) 260-9466. cc : Director, OERR OSWER Audit Follow-up Coordinator OERR Audit Follow-up Coordinator Other program staff, as appropriate Figure 7: Example of an OIG Response 19 ------- MEMORANDUM Subject: GAO Final Audit Report on Program Review, RCED-93-50 From: Elliott P. Laws Assistant Administrator To: Jonathan Z. Cannon Assistant Administrator Office of Administration and Resources Management The purpose of this memorandum is to transmit our response to the recommendations contained in the subject audit report. Recommendation to the AA. OSWER (page 10): Encourage and provide support for the Regions in establishing cost recovery units. OSWER Response: We accept this recommendation, and the AA, OSWER, will hold a telephone conference with the RAs to discuss issues regarding the establishment of cost recovery units. In addition, we will provide HQ staff in OERR to act as a clearinghouse for information regarding the establishment of cost recovery units. Milestones: Completed Telephone conference with RAs held on 9/30/90 to discuss cost recovery unit establishment issues. 5/30/91 OERR support staff will be prepared and on-line to provide information to the Regions on establishing ¦ cost recovery units. Thank you for the opportunity to comment on this subject report. If you have any questions, please call Charlene Dunn, OSWER Audit Follow-up Coordinator, at (202) 260-9466. cc: Director, OERR OSWER Audit Follow-up Coordinator OERR Audit Follow-up Coordinator Other program staff, as appropriate Figure 8: Example of a GAO Response 20 ------- When preparing either an OIG or GAO response involving several offices, versus sole responder audits, the following header format should be used: Subject: Audit Report Title and Number From: Henry Longest, director Office of Emergency and Remedial Response To: Laurie May, Director Organizational Management and Integrity Staff Figure 9: Example Header for Responses Requiring more than one Office If an audit report has Regional implications, Regional review and comment must occur before forwarding the response to the AA for signature. In addition, the name of the Regional contact and phone number should be attached to the response. If an audit report does not require a response, a formal memorandum is not required. Instead, OPM should address a note to Charlene Dunn, OSWER 10 stating that OERR has no comments to the subject audit report. Routing and Distribution of Audit Responses Once a response to an audit report is prepared in the proper format, the author sends a copy of the response through the management chain of command. Routing is facilitated by attaching a routing slip to the Response Package. A sample routing slip is shown in Figure 10. Before the response is reviewed by the OERR Director and signed by the AA for OSWER, it is reviewed by the appropriate managers including the Division Director and the OERR AFC. In addition to routing audit responses using routing and transmittal slips, response authors should provide the response electronically on the OERR Local Area Network (LAN). Responses are copied into a computer file and placed in the OERR LAN shared directory under subdirectory AUDITFMF. 21 ------- ROUTING AND TRANSMITTAL SLIP Date 3/17/92 TO: (Name, office symbol, room number, building, Agency/Post) Originator Initials Date 2. Originator's Section Chief 3. Originator's Branch Chief 4. Originator's Division Director OERR AFC/Correspondence Control Action File Note and Return Ad dt oval Fa Clearance Per Conversation As Reauested For Correction Prepare Replv Circulate For Your Information See Me Comment Investiaate Sia nature Coordination Justifv REMARKS 6. Director, Office of Emergency and Remedial Response (OERR) 7 . OSWER AFC 8. Assistant Administrator, Solid Waste and Emergency Response (Signature) RE: OSWER Response to Draft Special Report E1SFF1-11-0015 "Appropriateness of Accomplishments Claimed in CERCLIS for Fiscal 1990" Reference: File Title DO NOT use this form as a RECORD of approvals, concurrences, disposals, clearances and similar actions FROM: (Name, org. symbol, Agency/Post) Room No.Bldg. Originator Phone No. 5041-102 OPTIONAL FORM 41 (Rev. 7-76) Prescribed by GSA ~ U.S.G.P.O 1991 281-781/40010 FPMR (41CFR) 101-11.206 Figure 10: Example of Completed Routing and Distribution Slip 22 ------- d. Phase Four of the Audit Process Early Warning and Notification Entrance Conference Survey Phase Draft Report Response Requirement Exit Conference ^ Final Report Response Requirement Audit Follow-up and Reporting Figure 11: The Fourth Phase of the GAO and OIG Audit Process Audit Follow-up and Reporting OSWER/OERR has three systems for tracking corrective action implementation and other audit management activity: the Management audit tracking system (MATS), the Superfund Response Implementation System (SRIS), and the Milestone Tracking System (MTS). MATS, SRIS, and MTS together provide the basis for annual milestone reporting to the GAO, OIG, and OMB. MATS is the Agency's official audit tracking system. This system focuses on audit responsibilities at the Assistant Administrator's level. The OSWER AFC is responsible for updating audit recommendations, milestones, and completion dates in MATS. OSWER produces the Inventory of Audit Activity report every other month by using the information recorded in this system. Selected portions from MATS are included in the OIG Semiannual Report to Congress. OERR requires additional detail to successfully manage audit activity. As a result, SRIS was developed to track major events within the life cycle of an audit. SRIS maintains status information regarding all newly initiated, ongoing, or closed-out audits and milestones. The OERR AFC uses SRIS to track corrective actions that OERR is responsible for implementing. This system is used to update the information contained in the OSWER Inventory Report. For a more detailed description of SRIS functions and operations, please refer to the accompanying guide, The SRIS System Overview and Users' Guide (EPA 9200.8-05-1). OERR Divisions use MTS, accessed through the OERR LAN, to manage corrective action milestones. When Divisions submit corrective actions in an audit response, a new 23 ------- workplan is created in MTS. This workplan includes corrective actions, in the form of milestones, as well as any interim or process milestones. SRIS tracks the status of milestones reported in MTS through an electronic transfer of data. SRIS is also used to assist in preparing status reports of upcoming and overdue milestone completions. If a milestone date must be changed, a memo indicating why the milestone cannot be completed and its new projected completion date should be attached to the status reports on upcoming and overdue milestones. Status reports must be submitted quarterly (or more frequently, if requested) until all milestones are completed. Figure 12 contains an example of a Status Report Memo. MEMORANDUM Subject: Audit Follow-up; Update of Milestone Activity for OIG Audit of the Sample Management Office From: Tom Sheckells, Director Office of Program Management To: Laurie J. May, Director Organizational Management and Integrity Staff The purpose of this memorandum is to transmit an update of milestone activity for the subject audit report. Attachment I provides a listing of completed milestones as well as milestones for which our planned completion dates have been modified. The remaining attachments serve as documentation for completed milestones. If you have any questions, please call Sharon Hallinan at (703) 603-8894. Attachments cc: Charlene Dunn Howard Fribush Sharon Hallinan Figure 12: Status Report Memo 24 ------- Milestone tracking ends only after all corrective actions are completed. When preparing a status report on upcoming and overdue milestones for the OSWER AFC, the milestone information should be taken directly from the OSWER inventory. In addition, each milestone date and title should be repeated, with either a description of the action taken and documents produced that satisfy this milestone, or a request for an extension and a new proposed completion date. Figure 13 contains an example of the Milestone Update Section. Exhibit 4-9 OSWER Inventory 04/01/93 Identify problems with the Funding System This milestone is complete. Attachment II serves as documentation. This documentation, in chart form, allows us to determine delays in processing funding documents by examining the durations between steps in the process. After determining the point in which the delay occurred, a solution to process documents more timely can be determined. Figure 13: Milestone Update Section Due to the large number of GAO and OIG on-going audits, it is essential for managers to closely monitor audit follow-up responsibilities, and maintain milestone status for reporting. 25 ------- Appendix A: Glossary of Audit Terms Action Official: Audit Agency: Audit Closeout: Audit Finding: Audit Follow-up: Audit Life Cycle: The person responsible for all activities associated with a specific audit. Activities include responding on behalf of the Agency to draft and final reports. The agency responsible for investigating and evaluating programs, activities, and financial operations. For EPA the two primary audit agencies are GAO and OIG. The results of OIG accepting EPA's response to the final report. Any error, weakness, deficiency, problem, or need for improvement that is identified and detailed in an audit report. The process of taking corrective actions to implement recommendations, monitor corrective actions, and report on progress made towards implementation of milestones. The major events in an audit from the Entrance Conference to the Closeout. Audit Recommendation: An aspect of a program identified in an audit report with specific advice to: (1) improve an operation or procedure; (2) achieve compliance with applicable laws, regulations, and directives; and/or (3) assure that all costs charged are allowable under Agency regulations and applicable Federal cost principles. A process for resolving disagreements between Agency management and auditors on corrective action to be taken, reported findings, or recommendations. A written document addressing each finding or recommendation in an audit report by stating agreement/ disagreement and setting forth appropriate corrective action milestones to implement recommendations. Corrective Action: Any measure or course of action taken to implement an agreed- upon audit recommendation. Correspondence Control: A step in the process of assigning audit reports to specific managers for response, then assigning a POD number. A-1 Audit Resolution: Audit Response: ------- Documentation: Written verification to support a completed corrective action milestone. Draft Report: A preliminary report of the findings and sometimes recommendations for the purpose of obtaining comments from the audited program or Agency. Entrance Conference: The official meeting held at the beginning of an audit to explain the purpose, scope, objectives, and a timetable for completing the audit. Exit Conference: A meeting after the draft report has been issued to discuss findings and recommendations, clarify issues addressed in the audit, and resolve disagreements. Final Report: The report released after the exit conference that contains the most recent findings and recommendations of the audit agency. Final reports are official documents. Management Audit Tracking System (MATS): The official Agency system for tracking corrective actions and other audit activity. MATS is not available below the Assistant Administrator level. Milestone: An agreed-upon target used to measure the implementation of corrective actions. Milestone Closeout: The step taken when a milestone is accomplished and adequately documented. Milestone Tracking System (MTS): The system used by OERR Divisions for tracking general workplans as well as milestones created to implement corrective actions from audits. Red Border Review: A final review of an audit response (to GAO reports only) after all individual responses have been consolidated into one by the AA or GAO Liaison officer before it is presented to GAO. Superfund Report Information System (SRIS): The OERR system used to track major events within the life- cycle of an audit, to manage audit activity at the program office level, and to perform ad hoc queries and reports to assist Superfund managers in their audit responsibilities. Survey Phase: The step in the audit process in which the auditors begin to collect data for the audit. A-2 ------- Weakness: An identified error, deficiency, problem, or need for improvement listed by the audit agency in the audit report. Some weaknesses, deemed "material," warrant the attention of Congress and the President. Workplan: A document written by the responsible division explaining the steps they will take, including milestones, to implement corrective actions and recommendations included in the audit A-3 ------- |