Report 2017-119 Recommendations

When an audit is completed and a report is issued, auditees must provide the State Auditor with information regarding their progress in implementing recommendations from our reports at three intervals from the release of the report: 60 days, six months, and one year. Additionally, Senate Bill 1452 (Chapter 452, Statutes of 2006), requires auditees who have not implemented recommendations after one year, to report to us and to the Legislature why they have not implemented them or to state when they intend to implement them. Below, is a listing of each recommendation the State Auditor made in the report referenced and a link to the most recent response from the auditee addressing their progress in implementing the recommendation and the State Auditor's assessment of auditee's response based on our review of the supporting documentation.

Recommendations in Report 2017-119: California State University: It Has Not Provided Adequate Oversight of the Safety of Employees and Students Who Work With Hazardous Materials (Release Date: April 2018)

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Recommendations to Channel Islands, California State University
Number Recommendation Status
11

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Channel Islands should ensure that its joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement. If such committee does not exist, it should work with the union to form it by September 2018.

Fully Implemented
15

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Channel Islands should ensure that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

Fully Implemented
25

To more effectively provide oversight of its chemical plan, Channel Islands should annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions.

Fully Implemented
32

To ensure the health and safety of employees working with hazardous materials, Channel Islands should, by June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.

Fully Implemented
36

To ensure the health and safety of employees working with hazardous materials, Channel Islands should, by December 2018, make the required trainings available to employees and establish procedures for ensuring that the employees have received all required trainings.

Fully Implemented
40

To ensure the health and safety of employees working with hazardous materials, Channel Islands should, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

Fully Implemented
44

To ensure that employees working in a laboratory setting receive current information regarding laboratory safety, Channel Islands should provide periodic refresher laboratory safety training to these employees beginning in the Fall 2018 semester.

Fully Implemented
46

To ensure the health and safety of students in a laboratory setting, Channel Islands should work with appropriate faculty to develop student safety training acknowledgement forms by June 2018.

Fully Implemented
49

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Channel Islands should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

Fully Implemented
70

Channel Islands should immediately begin following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. Further, Channel Islands should amend its chemical plan to include specific expectations about how often departments and its EH&S office will conduct self-audits.

Partially Implemented
Recommendations to Sacramento, California State University
Number Recommendation Status
12

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Sacramento should ensure that its joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement. If such committee does not exist, it should work with the union to form it by September 2018.

Fully Implemented
16

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Sacramento should ensure that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

Fully Implemented
19

To increase its oversight of chemical safety, Sacramento should establish a chemical committee consistent with its chemical plan requirements.

Fully Implemented
20

To increase its oversight of chemical safety, Sacramento should, by June 2018, specify how often the new chemical committee should meet and then ensure that it meets as frequently as required and that it proactively addresses issues related to chemical hygiene and safety on campus.

Fully Implemented
21

To increase its oversight of chemical safety, Sacramento should ensure that the new chemical committee records its meeting minutes and makes those minutes available to all employees.

Fully Implemented
26

To more effectively provide oversight of its chemical plan, Sacramento should annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions.

Fully Implemented
29

To ensure that it has a chemical plan that is up to date and reflects current campus practices, Sacramento should develop and implement a revised chemical plan by January 2019.

Fully Implemented
33

To ensure the health and safety of employees working with hazardous materials, Sacramento should, by June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.

Fully Implemented
37

To ensure the health and safety of employees working with hazardous materials, Sacramento should, by December 2018, make the required trainings available to employees and establish procedures for ensuring that the employees have received all required trainings.

Fully Implemented
41

To ensure the health and safety of employees working with hazardous materials, Sacramento should, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

Fully Implemented
45

To ensure the health and safety of students in a laboratory setting, Sacramento should, by June 2018, develop campuswide policies to ensure that its departments are accountable for providing student training on laboratory safety.

Fully Implemented
47

To ensure the health and safety of students in a laboratory setting, Sacramento should work with appropriate faculty to develop student safety training acknowledgement forms by June 2018.

Fully Implemented
50

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Sacramento should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

Fully Implemented
53

To ensure the health and safety of students in a laboratory setting, by May 2018, Sacramento should remind all departments to retain student training acknowledgment forms for at least three years after the end of classes.

Fully Implemented
55

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Sacramento should perform reviews at least annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

Fully Implemented
62

Sacramento should monitor the implementation of its new processes for inspecting safeguards to ensure that it completes monthly flushes of eyewashes and showers as state regulations require.

Partially Implemented
63

Sacramento should immediately assess the health and safety risks in its art sculpture lab and take action to ensure that safeguards are readily accessible as state regulations require.

Fully Implemented
72

Sacramento should immediately begin following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. Further, Sacramento should ensure that its self-audits review whether timely flushes of eyewashes and showers have occurred.

Fully Implemented
75

Sacramento should immediately ensure that the entrances to all mechanical rooms with asbestos or material presumed to contain asbestos have signage to inform employees about the presence of the hazardous substance.

Fully Implemented
Recommendations to San Diego, California State University
Number Recommendation Status
13

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, San Diego should ensure that its joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement. If such committee does not exist, it should work with the union to form it by September 2018.

Fully Implemented
17

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, San Diego should ensure that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

Fully Implemented
27

To more effectively provide oversight of its chemical plan, San Diego should annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions.

Fully Implemented
30

San Diego should ensure that its chemical plan clearly defines the campus entity or individual who is responsible for reviewing and evaluating the effectiveness of its chemical plan at least annually.

Fully Implemented
34

To ensure the health and safety of employees working with hazardous materials, San Diego should, by June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.

Fully Implemented
38

To ensure the health and safety of employees working with hazardous materials, San Diego should, by December 2018, make the required trainings available to employees and establish procedures for ensuring that the employees have received all required trainings.

Partially Implemented
42

To ensure the health and safety of employees working with hazardous materials, San Diego should, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

Partially Implemented
51

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, San Diego should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

Fully Implemented
54

To ensure the health and safety of students in a laboratory setting, by May 2018, San Diego should remind all departments to retain student training acknowledgment forms for at least three years after the end of classes.

Fully Implemented
56

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, San Diego should perform reviews at least annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

Pending
64

San Diego should immediately develop and implement a plan to ensure that it consistently completes its flushes of eyewashes and showers monthly as state regulations require.

Fully Implemented
67

San Diego should continue to implement its new policy to regularly review open work orders to ensure that it closes work orders in a timely fashion.

Pending
68

San Diego should immediately develop and implement a plan to ensure that it consistently completes its inspections of air handler units at least annually.

Fully Implemented
73

San Diego should ensure that it documents all self-audits it conducts, including when it does not identify any violations during the audit. Further, San Diego should continue to implement and follow its new process to include reviews of safeguard inspections as a part of its self-audits.

Pending
74

San Diego should immediately ensure that the entrances to all mechanical rooms with asbestos or material presumed to contain asbestos have signage to inform employees about the presence of the hazardous substance.

Fully Implemented
Recommendations to Sonoma State University
Number Recommendation Status
14

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Sonoma should ensure that its joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement. If such committee does not exist, it should work with the union to form it by September 2018.

Fully Implemented
18

To ensure that it receives feedback from employee representatives on conditions associated with their work environments and that it develops appropriate interventions, Sonoma should ensure that its joint committee records meeting minutes and provides copies of the minutes and other information to the systemwide joint committee, as requested.

Partially Implemented
22

To increase oversight of chemical safety, Sonoma should, by June 2018, specify in its chemical plan how often its chemical committee should meet.

Fully Implemented
23

To increase oversight of chemical safety, Sonoma should ensure that its chemical committee meets as frequently as required and that it proactively addresses issues related to chemical hygiene and safety on campus.

Partially Implemented
24

To increase oversight of chemical safety, Sonoma should ensure that its chemical committee records its meeting minutes and makes those minutes available to all employees.

Fully Implemented
28

To more effectively provide oversight of its chemical plan, Sonoma should annually evaluate its chemical plan for effectiveness and document the results of that evaluation, including its discussions of any recommended revisions.

Fully Implemented
31

To ensure that its chemical plan is updated to reflect current practices and changes to how the campus may have evolved, Sonoma should immediately update its chemical plan.

Fully Implemented
35

To ensure the health and safety of employees working with hazardous materials, Sonoma should, by June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.

Fully Implemented
39

To ensure the health and safety of employees working with hazardous materials, Sonoma should, by December 2018, make the required trainings available to employees and establish procedures for ensuring that the employees have received all required trainings.

Partially Implemented
43

To ensure the health and safety of employees working with hazardous materials, Sonoma should, going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

Partially Implemented
48

To ensure the health and safety of students in a laboratory setting, Sonoma should work with appropriate faculty to develop student safety training acknowledgement forms by June 2018.

Fully Implemented
52

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Sonoma should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.

Pending
57

To ensure the health and safety of students in a laboratory setting, beginning in the Fall 2018 semester, Sonoma should perform reviews at least annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

Pending
65

Sonoma should continue to implement and adhere to its plan to ensure that it flushes showers and eyewashes and that it inspects fire extinguishers monthly as state regulations require.

Partially Implemented
66

Sonoma should add preventative maintenance work orders to its work order system by September 2018 to ensure that it completes fume hood and biosafety cabinet inspections annually as state regulations require.

Partially Implemented
69

By September 2018, Sonoma should begin using its work order management system to track and ensure preventative maintenance inspections of air handler units are completed at least annually.

Partially Implemented
71

Sonoma should immediately begin following its policies to conduct departmental self-audits to identify and address safety concerns in its laboratories. Further, Sonoma should ensure that its self-audits review whether timely flushes of eyewashes and showers have occurred. As part of self-audits, Sonoma's departments should ensure that fume hoods have received annual inspections. Finally, Sonoma's EH&S department should regularly review whether departments are conducting self-audits.

Partially Implemented
Recommendations to University, California State
Number Recommendation Status
1

To ensure that it provides effective oversight of health and safety issues on the campuses, the Chancellor's Office should, by September 2018, review and identify all recommendations issued to the Chancellor's Office and the campuses from the University Auditor's systemwide audits of campus health and safety practices since 1994.

Fully Implemented
2

To ensure that it provides effective oversight of health and safety issues on the campuses, the Chancellor's Office should, using the information from recommendation 1, develop and implement a plan by January 2019 to ensure that the campuses have taken appropriate actions to comply with health and safety requirements.

Fully Implemented
3

To ensure that it provides effective oversight of health and safety issues on the campuses, the Chancellor's Office should, by November 2018, develop a uniform health and safety reporting template and require the campuses to use it to annually report information related to campus health and safety, including data regarding employee and student training and any other areas the Chancellor's Office considers critical to its oversight of health and safety compliance. In developing this reporting template, the Chancellor's Office should consider the information from its own health and safety-related audits as well as the findings and recommendations of this audit.

Partially Implemented
4

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor's Office should assess the data and information in the reports to identify trends, risks, and best practices.

Pending
5

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor's Office should develop recommendations for improving campus health and safety and follow up on the campuses' implementation of any corrective actions related to these recommendations.

Pending
6

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor's Office should incorporate the risks identified in its assessments into the University Auditor's audit plan to ensure that the University Auditor evaluates problem areas related to campus health and safety.

Pending
7

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor's Office should follow up with campuses that fail to submit the required annual health and safety reports and take appropriate steps to ensure compliance with this requirement.

Pending
8

To ensure that it identifies systemwide trends and makes appropriate recommendations to address health and safety issues, the Chancellor's Office should work with the appropriate union to form a systemwide joint committee, as agreed upon in its bargaining agreement with the union, by September 2018.

Fully Implemented
9

To ensure that it identifies systemwide trends and makes appropriate recommendations to address health and safety issues, the Chancellor's Office should ensure that the systemwide joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement by actively working with the union on an ongoing basis.

Fully Implemented
10

To ensure the health and safety of employees working with hazardous materials, the Chancellor's Office should prescribe the frequency for which the campuses provide refresher laboratory safety training to employees.

Pending
58

As part of the uniform health and safety-reporting template that we recommend that it develop, the Chancellor's Office should require campuses to annually report on the timeliness of their inspections of safeguards, engineering controls, and ventilation systems and identify the reasons for any delays.

Pending
59

Based on campuses annual reports on the timeliness of their inspections of safeguards, engineering controls, and ventilation systems, the Chancellor's Office should follow up with campuses that report untimely inspections and should require that the campuses develop action plans to ensure that they complete inspections as often as state regulations require.

Pending
60

To ensure compliance with state requirements to notify employees about the presence of asbestos, the Chancellor's Office should immediately remind all of its campuses that state regulations require posting signage at the entrances to mechanical rooms that contain asbestos.

Fully Implemented
61

To ensure compliance with state requirements to notify employees about the presence of asbestos, the Chancellor's Office should, by September 2018, ensure that campuses are compliant with the requirement to post warning signage at the entrances to mechanical rooms that contain asbestos.

Partially Implemented


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