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February 27, 2008
Auditor General Issues Semi-annual Report
Nova Scotia Auditor General

A performance audit was done for the environmental monitoring and compliance division of the Department of Environment and Labour. It found a number of improvements are needed to ensure environmental protection laws are followed with respect to industrial sites, pits and quarries, the management of dangerous goods, and other environmentally sensitive areas. There were cases where work approvals were given when they should not have been, cases of no or inadequate inspections, and poor follow-up to see that deficiencies had been corrected.

The full report is available on the auditor general's website at www.gov.ns.ca/audg or by contacting the office at (902)424-4108 or oaginfo@gov.ns.ca .

Section of AG's report on NS Environment Department

3 Environment and Labour: Environmental Monitoring and Compliance

Summary

The quality of our environment can have a significant impact on the lives of Nova Scotians. Pollutants and other contaminants can negatively affect human health and the competitiveness of our economy. The Environmental Monitoring and Compliance Division of the Department of Environment and Labour is responsible for environmental protection and the delivery of enforcement-based compliance programs which are vital to ensure a healthy environment. We completed a performance audit at the Division, examining their policies, procedures and processes to ensure compliance with the Environment Act.

An efficient and effective approval process is essential to ensure those engaging in environmentally sensitive activities do so in a safe and legal manner. Monitoring and inspecting are means to verify that individuals and businesses are meeting their regulatory requirements under the Environment Act. Enforcement is necessary when voluntary compliance with the Act cannot be achieved.

The Division's policies and procedures for issuing approvals, inspections and enforcement are not adequate as implemented. We found instances where required procedures were not performed

approvals were issued without all documentation in place, required inspections were not completed, enforcement actions were inadequate to ensure compliance, and complaints were not followed up. While a policies and procedures framework is in place, to be effective, the Division must ensure all required policies and procedures are followed.

An effective quality assurance process is an important control to identify and correct noncompliance with internal policies and procedures as noted above. The Division has begun to develop a quality assurance process which is still in the testing phase. We believe the Division needs to fully implement a quality assurance process as soon as possible.

Management information systems are not adequate for the Division to manage its responsibilities. Information is not complete, reliable and accurate. As a result, management are not aware of the extent and completeness of monitoring, inspection and enforcement activities carried out by staff. The Division must ensure current systems are fully utilized, meet user needs and have complete and accurate data.

3.1 Under the Environment Act, the Department of Environment and Labour is responsible to protect and preserve the environment through delivery of regulatory and non-regulatory programs. Within the Department, the Environmental Monitoring and Compliance Division (EMC) is responsible for operations relating to environmental protection; including issuing approvals, monitoring, inspections, and enforcement. EMC's core programs are organized around hazardous substance management (dangerous goods, industrial facilities, pesticides), waste management (on-site sewage, wastewater, solid waste), and water resource management (treatment, allocation, watercourse alteration).

3.2 For operational purposes, the province is divided into four regions. A regional manager oversees each region, with one or more districts within each region under the direction of a district manager. This network of regional and district offices provides environmental compliance coverage to all areas of the province.

3.3 In 2006-07, actual expenditures for the Environmental Monitoring and Compliance Division were $8.6 million. For 2007-08 the budget for the Division was $10.4 million from a total department budget of $34.7 million. The Division employs approximately 70 inspectors throughout the four regions. Inspectors are supported by Division resource staff such as engineers, compliance and inspection coordinators, and hydrogeologists. Audit Objectives and Scope

3.4 In October 2007 we completed a performance audit at the Environmental Monitoring and Compliance Division of the Department of Environment and Labour. The audit was conducted in accordance with Section 8 of the Auditor General Act and auditing standards established by the Canadian Institute of Chartered Accountants and included such tests and procedures we considered necessary in the circumstances.

3.5 The objectives for this assignment were to determine whether:

- the processes for issuing approvals are adequate to ensure compliance with the Environment Act;

- monitoring, inspection and enforcement processes are adequate to ensure compliance with the Environment Act;

- systems and processes for handling complaints from the public concerning violations of the Environment Act are adequate; and - information systems and processes to manage the Division's compliance responsibilities under the Environment Act are adequate.

3.6 Our audit focused on the Environmental Monitoring and Compliance Division's processes and procedures surrounding industrial and dangerous goods management activities. Generally accepted criteria consistent with the objectives of the audit do not exist. Audit criteria were developed specifically for the engagement using both internal and external sources. Criteria were discussed with and accepted as appropriate by senior management of the Division.

3.7 We conducted audit work at the four regional offices from August to October. We interviewed management and staff; examined policies, files and other documentation deemed to be relevant; reviewed systems; and tested certain processes and procedures. Significant Audit Observations

Approvals

3.8 Conclusions and summary of observations

We assessed whether the processes for issuing approvals were adequate to ensure compliance with the Environment Act. We concluded that while the Division's framework for issuing approvals reflects the requirements in the Environment Act and regulations, this framework is not always followed. We noted the Division issued many approvals without all required documentation in place. An efficient and effective approval process is essential to ensure those engaging in environmentally sensitive activities do so in a safe and legal manner. Failure to follow the approval process can lead to applicants engaging illegally in those activities and, more importantly, causing preventable damage to the environment.

3.9 Approval process

Under the Activities Designation Regulations, the Department must issue an approval for any activity which has the potential to cause an adverse effect on the environment. We examined the process for obtaining approvals to engage in industrial and dangerous goods management activities. We found the application process was standardized across the province, clearly presented, and reflected requirements of the Act and regulations. We selected 60 active approvals from all areas of the province issued prior to 2006 and tested compliance with policies and procedures. We observed the following.

- Applicants are required to provide proof they own the site on which the proposed activity will take place or have a lease or other agreement that allows them to conduct the activity on the site. We found three cases (5%) where there was no proof that the applicant owned or had the right to use the site. If such documentation is not obtained, applicants could receive an approval to conduct activity on land they do not have the right to use. This could result in legal or financial consequences for the Department.

- Regulations require the applicant provide security equal to estimated site rehabilitation costs when undertaking certain activities. If financial security is not obtained before issuing an approval and kept current, the Department could become responsible for potentially significant site clean-up costs. We noted three cases (5%) where required financial security was either not obtained or not kept up-to-date. We noted similar concerns with financial security during an audit of the Department in 1993.

- In addition to the standard terms and conditions set out in the Act and regulations, an applicant may be required to provide other documentation or meet certain requirements that are specific to the activity or the site on which the activity will be carried out. Approval documents include specific terms and conditions. We found two cases where approvals were issued before the specific terms and conditions were met. In three other cases, the Division required the applicant meet specific terms and conditions within a short time after the approval was issued. There was no evidence these terms and conditions were ever met. The risk an activity is not carried out in the safest possible manner and could have a negative impact on the environment is increased if an approval holder does not meet all required terms and conditions of an approval.

- In certain cases required documents were not provided such as contingency plans (18 cases

30%) and abandonment or rehabilitation plans (3 cases

5%). The Division cannot complete a full review of a proposed activity without obtaining all required documentation. Management indicated contingency plans are not always necessary. If certain documents are not necessary for a particular activity it should be noted in the file. There was no such documentation in the files we examined.

3.10 The Division must obtain all required documents to complete a full review of an activity. Failure to do so could result in significant consequences for the Department, such as responsibility for clean-up of an abandoned or contaminated site.

Recommendation 3.1

The Division should ensure that proof of ownership or right to use a site and all other documents are obtained, required financial security is in place, and all requirements are met before an approval is issued.

Monitoring and Inspections

3.11 Conclusions and summary of observations

We assessed whether monitoring and inspection processes are adequate to ensure compliance with the Environment Act. We concluded inspection processes are not adequate as the Division is not meeting its inspection requirements. We also noted monitoring processes could be improved. Monitoring and inspections are necessary to verify that individuals and businesses are meeting their regulatory requirements under the Environment Act.

3.12 Monitoring and inspection processes

We examined the monitoring and inspection processes intended to ensure approval holders are meeting the terms and conditions of their approvals. For certain types of approvals, approval holders are required to report regularly on aspects of their activities. Inspectors review these reports and follow up on noncompliant items. The Division accepts the information provided by approval holders in good faith. They do not perform periodic audit or other procedures to verify the accuracy and reliability of these reports. Submitted data could be inaccurate if equipment used to record the information is calibrated incorrectly or there were errors in gathering the data.

Recommendation 3.2

The Division should establish procedures to obtain objective evidence to validate the accuracy of monitoring reports received from approval holders.

3.13 Inspectors are required to carry out risk assessments for all operational industrial and dangerous goods management activities. The risk assessment is used to determine the frequency of subsequent inspections. We examined the files for 60 active approvals and tested whether monitoring and inspection activities were carried out as required. We observed the following.

- Risk assessments were not documented in the file in 16 cases (27%) although there were risk scores in the information management system in seven of those cases. If a risk assessment is not completed, it is possible inspections are not carried out at the appropriate frequency. This increases the risk of noncompliant activity going undetected (not inspecting enough) or inspection resources used unnecessarily (inspecting too often).

- For 23 cases (38%) where risk assessments were completed, inspections were not carried out as frequently as the risk rating indicated. There was no evidence in the files any inspections had been carried out for four (7%) of the cases we examined, although the information management system indicated some had been done. Staff in one region gathered information indicating 93 (42%) of their 222 industrial and dangerous goods management approvals had overdue inspections. The risk of damage to the environment through noncompliant activity is increased when inspections are not carried out.

- The files for a large operation did not contain current information. The most recent monitoring information was for the year 2000 and there were no inspection reports. The files were originally managed from one district office and later transferred to another office. Management indicated inspections were carried out regularly but the inspector responsible has since retired and the documentation could not be located.

- Inspectors complete a field inspection report that notes the details of the site and inspection results, including any noncompliant issues to be addressed. The inspector and the approval holder or representative sign the report. If the approval holder or representative does not sign, the inspector notes the reasons on the report. For 27 cases (45%) the approval holder had not signed the report and there was no explanation noted. Without some indication that the approval holder has been informed of the results of the inspection it is possible that noncompliant issues noted will not be addressed or will not be dealt with in a timely manner.

3.14 Inspections are a means to verify that activities are carried out in a manner that meets the requirements of the Environment Act. Risk assessments are a means to determine how often ongoing activities should be inspected. Inspection reports provide evidence of an inspection and the results. The signature of the approval holder or representative indicates they have been informed of the results of the inspection and any remedial action that must be taken. The risk that activity which could potentially damage the environment will go undetected or not be addressed in a timely manner is increased if the Division does not carry out inspections or does not complete them as frequently as required. Complete documentation of an inspection provides evidence the inspection has been carried out and the owner or representative informed of the results and any remedial actions required.

Recommendation 3.3

The Division should ensure risk assessments are completed and inspections carried out as frequently as required. Further, the Division should completely document inspections, including obtaining signatures or providing an explanation why they were not obtained.

3.15 A quality assurance process is a set of planned and systematic actions to provide confidence that a system is performing as required. Establishing such a process would assist the Division in addressing the issues noted above. The Division has begun to develop a quality assurance process to determine the degree of internal compliance with operational and administrative responsibilities. It is designed to detect and make correction in areas where improvement is needed and to maintain compliance with required procedures. A pilot project was implemented in late 2006 to test the first stages of the process. Testing of the remaining stages was to be completed in 2007. The pilot project focused on one of the Division's compliance programs. Preliminary results from the pilot project indicated some required procedures were not done and there were issues with completeness of documentation. The Division expects to implement the quality assurance process across all its compliance programs in the coming years.

Recommendation 3.4

The Division should implement the quality assurance process across all its compliance programs as soon as possible.

3.16 Management indicated that, in 2006, one region undertook an initiative to improve the organization and structure of its files. Another region developed a pilot project for records creation, maintenance and management. Periodic management review of inspectors' files is part of the process. Enforcement

3.17 Conclusions and summary of observations

We assessed whether enforcement processes are adequate to ensure compliance with the Environment Act. We found instances where the Division's enforcement actions were not adequate. Responsibility for enforcement is established in legislation and facilitated through Division policies and procedures. Enforcement may be used to achieve compliance with regulatory requirements and is necessary when voluntary compliance cannot be achieved.

3.18 Enforcement processes

We investigated the framework for enforcement of the Environment Act and regulations and determined that the authority, roles and responsibilities for enforcement are clearly presented in the Act, regulations and policies of the Department. Enforcing compliance can involve non-punitive measures, such as persuasion and education, as well as punitive measures such as summary offence tickets and prosecution. Inspectors determine which course of action to take. Inspectors are guided by the Department's compliance model (see Exhibit 3.3), investigation and enforcement tools, and consultation with compliance and investigation coordinators or the district manager.

3.19 Inspectors receive training in investigations and enforcement through a formal training program developed for the Department. As well, compliance and investigation coordinators provide periodic education and training on proper documentation of investigations and enforcement activities. In one region the coordinator is also involved in carrying out file reviews for proper and complete documentation.

3.20 We examined 90 files and noted instances where inspectors documented various noncompliant matters. We assessed measures taken to ensure these matters were corrected and made the following observations.

- Required procedures were followed for 13 cases where punitive measures, such as warnings, summary offence tickets or ministerial orders were used.

- Where non-punitive measures were taken, there was no evidence of follow-up by the inspector to ensure corrections were made in 15 cases. For seven of those cases, the noncompliant matters were not noted in later inspections.

- Persuasive measures were used repeatedly in eight cases and did not result in compliance for two of these cases. Compliance was not timely for five of the remaining cases.

- In one instance the approval holder did not comply with the regulations and was not cooperative with inspectors. Persuasive measures were continually used with no effect. We were informed that other methods were deemed not viable because the approval holder was unlikely to heed a warning or pay a ticket due to limited financial means.

- In one case punitive measures were initiated but not continued due to lack of proper support for the action. The inspector's ability to act was impaired due to insufficient documentation from a previous inspector's contacts with the approval holder.

3.21 Timely and appropriate use of enforcement can improve compliance and serve as a deterrent. The Division cannot ensure compliance if enforcement procedures are ineffective

lack of follow up on noncompliance or repeated use of unsuccessful non-punitive measures.

Recommendation 3.5

District management should monitor the work of the inspectors to ensure they follow up on noncompliance in a timely manner and use appropriate enforcement measures.

Complaints

3.22 Conclusions and summary of observations

We assessed whether systems and processes for handling complaints from the public concerning violations of the Environment Act are adequate. We concluded the Division does not have adequate systems to track and monitor public complaints. While the Division has established policies and procedures for recording, investigating and concluding on complaints, we noted a number of instances where they did not follow required procedures. Public complaints are a significant source of information on activities that may impact the environment. It is important that the Division properly record and investigate complaints received to ensure an appropriate response is made to protect the environment.

3.23 Tracking systems

The Division does not have a single, province-wide complaints tracking system. Each region has its own system for recording, tracking and responding to complaints. In three regions, complaints are managed and monitored through computerized databases. Two databases have the ability to track the status of a complaint and generate reports. The third database has limited reporting capabilities and does not provide status information. The fourth region manages and monitors complaints using a spreadsheet which allows for tracking the status of a complaint but does not readily provide reports on the information gathered.

3.24 We tested 30 complaints files and noted the following.

- There were six instances where complaints were documented in the files and followed up but not listed in the complaints tracking system.

- In two cases, the tracking system showed open complaints although investigations were completed and documented as closed in the file.

- Complaints investigations were completed but the files were not closed in eight cases.

- There were four complaints listed in the tracking system where there was no evidence the complaints were investigated.

- Inspectors did not contact the complainant after investigation of the complaint, as required by policy, in seven cases.

- The inspector's contact with the complainant was not timely in one case.

3.25 Inspectors spend a considerable amount of their time following up and investigating complaints. If tracking systems do not have accurate information on the number and status of complaints investigations, management may not be able to determine the full extent of the workload of inspectors and therefore be unable to fully manage their resources. If the Division does not follow all required procedures, complaints may not be investigated appropriately which could result in harm to the environment.

Recommendation 3.6

Management should ensure that information entered into the complaints tracking systems is complete and accurate and that policies and procedures for handling complaints are followed.

3.26 The Department is in the process of implementing a tracking system which will capture and track a variety of activities, including complaints. Management informed us this system will be available in all regions and across all divisions of the Department. It is currently being implemented in one division and is not expected to be in operation for the Environmental Monitoring and Compliance Division until at least 2009. Management Information Systems and Processes

3.27 Conclusions and summary of observations

We assessed the adequacy of information systems and processes to manage the Division's compliance responsibilities under the Environment Act. We concluded that management information systems and data are not adequate. Information systems do not provide management with complete, reliable and accurate information regarding the extent of monitoring, inspection and enforcement activities carried out by staff. To make informed decisions, management needs information that is relevant, reliable, up-to-date and readily accessible.

3.28 Management processes

Regional managers communicate and meet regularly with district managers to obtain information on district issues, provide direction and outline priorities. District managers are responsible for daily management of inspection staff and have daily or regular discussion, communication and meetings with inspectors to keep up-to-date on activities. They also use reports and information from the Department's information management system, as well as other subsystems (spreadsheets and databases), to monitor work activity.

3.29 Information management system

The Division's information management system (EIMAS) was custom designed for the Department and implemented in 1999. The system was designed primarily for registration and approvals information. It does not include information on all the Division's responsibilities, such as contaminated sites and complaints. The Division uses spreadsheets and other databases to record these activities. EIMAS information is available to all staff. A number of standard reports on applications, approvals and inspections can be generated from the system.

3.30 When EIMAS was initially implemented data errors were made as staff learned to use the system. Corrections and improvements to the system addressed issues that arose, but data errors continue to be an issue. In 2005, staff carried out a review of industrial and municipal approvals to determine the prevalence of discrepancies between the expiry date in EIMAS and the date on the approval provided to the approval holder. The review found that approximately 30% of the expiry dates did not match. Improvements were noted in a 2006 follow-up review. However, there were still errors in 20% of the files reviewed. From our testing, we noted differences in expiry dates in ten (17%) of the files. While some of the differences in the dates were small (one month or less), there were others where the difference was one year or more. We noted one instance where the actual expiry date was over eight years past the EIMAS date. Incorrect expiry dates in the system could result in not scheduling and carrying out required inspections or operators continuing to operate without a valid approval.

3.31 Management monitors work activity with the Application/Approval Activity Summary, an EIMAS report. This report shows the progress of applications from initial receipt through to final disposition. We extracted a report of industrial and dangerous goods applications that were listed as under review. Of the 101 applications, we noted 84 dated between 1999 and 2006. We were told possible reasons why these applications are still under review could be due to waiting for missing information, failure to close a completed file or an approval was issued but not recorded in EIMAS. We examined 29 files and were informed that in at least seven cases the application had been approved and issued but not recorded in EIMAS. In at least four other cases the file should have been closed.

3.32 During our audit, management expressed concern that data in EIMAS was not accurate and did not necessarily reflect the inspection files. One region developed a spreadsheet that outlined approval and inspection information for industrial and other files and noted differences with the information in EIMAS. Staff used this information to follow up and correct discrepancies. At the time we reviewed the spreadsheet, there were 24 files (11%) where information in EIMAS was incorrect or missing. We were informed that another region carried out a project to review their files and correct any errors in EIMAS. We did not audit the results of this review. A third region uses a separate database to track certain inspector activities.

3.33 Inspectors can use EIMAS to schedule inspections based on the risk rating of the approved activity. We found staff is not consistently and fully using these capabilities. Through our testing of inspection files, we noted inspections were carried out but not recorded in EIMAS. In other cases, inspections were recorded in EIMAS but there was no evidence in the file that inspections were completed. Since EIMAS is not consistently used to document monitoring and inspection activities, system reports on these activities are unreliable and have limited usefulness as a management tool.

3.34 Staff can use information gathered from monitoring, inspection and enforcement activities in building compliance histories of the regulated parties and determining the most appropriate response to incidents of noncompliance. Data can be combined and analyzed to provide information about compliance rates for a sector or geographic area. This information is also useful for program planning and management which are critical to ensuring the Division's compliance resources are employed in the most efficient and effective manner.

Recommendation 3.7

The Division should ensure compliance activities and other data are consistently and accurately captured in the information management system.

3.35 Managers in the regions rely on a variety of sources for information on enforcement activity. Some regions use spreadsheets to track certain types of enforcement activity. Compliance and investigation coordinators in some regions prepare monthly status reports on investigation and enforcement actions by inspectors. Managers may also meet regularly with the coordinators and individually with inspectors to discuss ongoing investigations and enforcement activities.

3.36 EIMAS is also used to capture enforcement actions although limited reports can be generated from this data. The system does not have the ability to create a complete, comprehensive status report on enforcement activity in a particular region or across the province. We reported a similar situation in our 2002 audit report on water safety. In our 2005 follow-up review, the Department noted a report writing program was now available that addressed the problem. In our discussions with management, they indicated there have been difficulties with the report writing program and reports are still not readily available.

Response: Department of Environment and Labour

This report supports measures already underway at the Environmental Monitoring and Compliance Division at the time of the audit and will be a useful tool as we bring those programs to completion.

The Division appreciates the recommendations in this report. We understand that the report is not critical of our policies and procedures, but does state that our implementation of them needs improvement. We accept that advice.

However, it must be noted that although errors and omissions in implementing policies and procedures have occurred, there is no indication from either the audit or from the department's experience that these errors and omissions have resulted in negative impacts to public health or the environment.

Many of the audits findings relate to information systems or quality assurance. The Department was already implementing a new information management system known as the Activity Tracking System at the time of the audit. The Division is scheduled to adopt ATS in 2009 and we anticipate significant improvements as a result.

This same point must be made about quality assurance. The Division successfully tested a quality assurance program on our public drinking water supplies in 2007, and in 2008 we will add municipal drinking water and one industrial sector to the program.

The role of the Risk Based Audit process should also be noted. The RBA recognizes that it is neither possible nor necessary for government to audit the performance of each of the 3,300 approved facilities currently in operation. Instead, the majority of our effort is focused on those activities where noncompliance poses the greatest risk. However, all operators are aware that inspections can and do occur at any facility, at any time.

The Division would like to thank the staff of the Office of the Auditor General for their professionalism and advice. On the seven specific recommendations, the Department offers the following comments:

APPROVALS

Recommendation 3.1

The Division should ensure that proof of ownership or right to use a site and all other documents are obtained, required financial security is in place, and all terms and conditions are met before an approval is issued.

The Division puts a great deal of work into ensuring that all appropriate documents, including proof of ownership and financial security, are provided before an approval is issued. There have been instances in which not all documents are present in project files.

Not every document listed in the approval regulations is required for every activity. At the time of application, proponents are advised by staff as to what conditions their project must meet. For example, a cemetery application does not require a contingency plan, but the application form does not reflect this practice.

This approach can cause confusion, and the Division will therefore prepare checklists clearly showing which submission documents are required for specific types of activities.

Monitoring and Inspections

Recommendation 3.2 The Division should establish procedures to obtain objective evidence to validate the accuracy of monitoring reports received from approval holders.

The Division validates the accuracy of monitoring reports according to the risks inherent in the activity. For example, the Division currently has a program to regularly validate water quality data for drinking water supplies.

It is not feasible for the Division to validate every monitoring report for the 3,300 approved activities with operational components. In some cases monitoring data is supplied by the operators, who are aware that their data is subject to verification and that filing false data is an offence under the Environment Act. In other cases, monitoring is conducted by reputable third-parties who are also aware of the consequences of false reporting.

Further, some activities, such as the surface coal mining, receive frequent unannounced visits from Division inspectors.

In response to this recommendation, the Division will review its system for validating monitoring reports.

Recommendation 3.3

The Division should ensure risk assessments are completed and inspections carried out as frequently as required. Further, the Division should completely document inspections, including obtaining signatures or providing an explanation why they were not obtained.

The Division routinely conducts unannounced inspections, which means the approval holder is not always on site to sign the inspection report. The Division will change its inspection form to include space to indicate why the report is not signed.

The Division will review its Risk Based Audit program and make changes to ensure appropriate risk criteria are used.

The Division will develop and implement, by 2009, procedures within the current quality assurance program to ensure that risk assessments are conducted and inspections are carried out in a timely manner.

Recommendation 3.4

The Division should implement the quality assurance process across all its compliance programs as soon as possible.

The Department will continue to implement the quality assurance process developed in 2006 and successfully tested in 2007 on our public drinking water supplies.

In 2008 the Division will expand its quality assurance program to municipal drinking water facilities and one sector of the industrial approval program. The phased expansion will continue until all appropriate activities are included.

Enforcement

Recommendation 3.5

District management should monitor the work of the inspectors to ensure they follow up on noncompliance in a timely manner and use appropriate enforcement measures.

Supporting the work of inspectors continues to be an important priority for management. Managers meet regularly with staff to discuss the status of their files and review noncompliance issues.

To build on this, the Department is currently implementing a new Activity Tracking System (ATS) across all operational divisions of the department. One component of ATS includes the capture and tracking of the status of noncompliance matters. Rollout of ATS to the EMC Division is scheduled for 2009.

Complaints

Recommendation 3.6

Management should ensure that information entered into the complaints tracking systems is complete and accurate and that policies and procedures for handling complaints are followed.

The new Activity Tracking System that is currently being implemented in the department includes a component for the capture and tracking of complaints. EMC division is scheduled to commence with ATS in 2009.

The EMC Division has developed a file building and maintenance procedure that includes an internal file audit process for handling complaints. The procedure is currently being piloted in one area of the province and will be extended in all regions in 2008. Management Information Systems and Processes

Recommendation 3.7

The Division should ensure compliance activities and other data are consistently and accurately captured in the information management system.

The division will develop and implement procedures within the current quality assurance program to ensure the consistency and accuracy of data entry into our information management system.

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