INTERNAL COMPLIANCE

AUDITING

Background, Process, and Tools for Success

presented by: Ronald Taylor, Environmental Affairs Compliance Manager

EPA states:… “it is USEPA policy to

encourage the use of environmental auditing to help achieve and maintain compliance and identify / correct unregulated hazards”…

THE EPA AUDIT POLICY

1. Systematic discovery though audits and management systems

2. Voluntary discovery3. Prompt disclosure (defined as

within 21 days)4. Discovery is independent of

government or 3rd party plaintiff5. Correction and Remediation

THE AUDIT POLICY

6. Prevent reoccurrence7. No repeat violations8. Some violations are excluded9. Cooperation

EPA INCENTIVES FOR AUDITING

• Gravity based penalties will not be pursued. (all 9 elements in place)

• 75% reduction in gravity based penalties. (elements 2 – 9 in place)

• No recommendation for criminal prosecution. (elements 2 – 9 in place)

• No routine request for audit reports.• Kentucky, if voluntary disclosure,

will not seek civil penalties.

HIGHER EDUCATION FOCUS

• Region 1 began in 2004– initial focus on educating the community– basic compliance– best management practices– sustainability

• UK received communication in 2007• Additional communication to UK

Healthcare in 2008

ADVANTAGES• Increased awareness• Helps drive accountability• Helps meet audit policy criteria• Recognition of exemplary practices• Identification of improvement

opportunities• Proactive response to compliance

KEYS FOR SUCCESS

• Upper management support• Good audit tools• Well defined audit criteria• Timely follow up and closure• An integrated approach

CHALLENGES

• Audit scope identification• Effective and timely closure• Corrective action verification• Accountability• Potential for FOIA requests

Knowledge is Power. To be forewarned is

to be forearmed

quoted from: “Environmental Audits and Inspections: What Every U (and University Attorney) Should Know

Michael Sermersheim and Ronald Baylor, June 2004

THE PROFILE

• Establishes audit scope• Based on activities within audited

entity• Accuracy is key

THE AUDIT

• Applicable questions built from profile

• Used for field evaluation• Good training tool

CORRECTIVE ACTION TRACER

• Compiles identified compliance issues

• Tracking tool for completion• May also add compliance due dates

and recommendations• May send reminder messages

SUCCESS STORIES

• Location asked for blank audit to use in training

• Last 2 campus regulatory inspections resulted in no Notices of Violation

• Enhanced communication between EMD and SAA’s