2017-119 Audit Scope and Objectives

California State University—Health and Safety Compliance

The audit by the California State Auditor will provide independently developed and verified information related to the health and safety compliance of the California State University (CSU) Channel Islands, Sacramento, San Diego, and Sonoma campuses, and will include, but not be limited to, the following:

  1. Review and evaluate the laws, rules, and regulations significant to the audit objectives.
  2. For the four selected CSU campuses, determine whether the campuses have adequately defined roles and responsibilities for employee and student safety by determining the following for each campus:
    1. Whether the campus has a Chemical Hygiene Committee and a Joint University Safety Committee in accordance with state or federal regulations. Also, determine how often these committees meet and whether minutes are taken and made available to employees upon request.
    2. Whether the roles and responsibilities for the Chemical Hygiene Officer, Laboratory Supervisors, and Principal Investigators are clearly defined, documented, and readily available to ensure worker safety.
    3. Whether the campus has a biosafety committee. If not, assess the appropriateness of not having such a committee.
    4. Whether the campus has qualified radiation and laser safety officers. If not, assess the appropriateness of not having such officers.
  3. For the four selected campuses, determine whether the campuses ensure adequate availability of safety equipment and monitor the proper operating conditions of such equipment. Specifically, determine the following for each selected campus:
    1. The extent to which the campus provides and requires proper personal protection equipment (e.g. lab coats, goggles, gloves, face masks, shields, etc.) and engineering controls (e.g. air filters, fume hoods, snorkels, etc.). Determine how often the engineering controls are checked to ensure effectiveness and adequacy for current working conditions and the average replacement and repair time for such equipment.
    2. Whether appropriate fire extinguishers, suppression systems, eye wash, emergency showers, and other safeguards are readily available, sufficient for current working conditions, and routinely checked to ensure proper operation.
    3. How often, and to what degree, the campus monitors air quality and checks ventilation systems where chemicals are stored and where technicians are near chemicals (e.g. stockrooms, employee offices, classrooms, hallways, storage facilities, etc.). Also, assess the method, the frequency, and the extent to which biosafety hoods and autoclaves are inspected and certified.
  4. For the four selected campuses, determine how each campus' procedures and practices for proper storage and safety of equipment ensure the following:
    1. Whether the campus adequately maintains controlled chemicals (e.g. flammable, acid, poison, gas, corrosives, etc.) with appropriate certifications and permits for every location where chemicals are maintained. Also, assess the adequacy of safeguards put in place to prevent unauthorized access to laboratories and storage locations where chemicals are kept.
    2. Whether the campus has properly labeled radiation sources. Also, determine whether the campus follows appropriate procedures to ensure that employees who access radiation sources are properly monitored in accordance with applicable laws and regulations.
  5. For the four selected campuses, assess the adequacy of each campus' safety program and student and employee access to information and training by determining the following:
    1. The extent to which employees have access to appropriate information for compliance with California Hazard Communication regulations or other applicable laws, Safety Data Sheets, standard operating procedures, and where this information is located.
    2. How and the extent to which the campus provides annual notifications for lead based paint, asbestos, and other carcinogens to campus employees and students. Also, assess whether areas containing lead, asbestos, and other carcinogens are properly marked.
    3. Whether the campus has clearly defined the roles and responsibilities of individuals in charge of campus protocols and training for the clean-up of incidences such as chemical spills, dead rodents, mice contamination, bodily fluids, needles, and syringes. Also, determine how the scope of the training is established.
    4. Whether the campus has a respiratory protection program and whether the program is designed to adequately protect employees and students.
    5. Whether the campus has a written blood pathogen program and radiation and laser safety program. Also, determine whether the campus has made employees aware of these programs and the extent to which training and competency of employees in these programs is documented.
    6. Whether the campus had adequate policies, protocols, and practices for training and supervising students on the hazards of the laboratory. Also, determine whether students and employees are provided safety training prior to working in the laboratories and are adequately supervised while working in teaching and research labs.
    7. Whether the campus has an ongoing training for quarantine procedures in the event of an outbreak of disease on campus.
  6. For the four selected campuses and the CSU Chancellor's Office, assess the monitoring of compliance with health and safety laws, regulations, policies, and procedures by determining the following:
    1. Whether the campus performs self-audits in teaching and research laboratories that use potential hazardous chemicals and equipment. If the campus does not perform self-audits, assess its reasons. If the campus performs self-audits, assess the following:
      1. The appropriateness of the frequency of these self-audits.
      2. The appropriateness of the frequency of audits performed by the campus' Environmental Health and Safety Office in the areas that use chemicals and equipment to ensure compliance. If no such audits are performed, determine why.
    2. Whether the CSU Chancellor's Office and campus Environmental Health and Safety Office have sufficient authority to require compliance with all applicable health and safety standards.
    3. The enforcement actions levied against the CSU Chancellor's Office and the campuses for health and safety violations during the past five years and the agencies that issued such actions.
  7. Identify the circumstances and the timeline surrounding when administrators at CSU Sacramento became aware of unsafe levels of lead in the campus drinking water and when the campus community was informed of this hazard. Assess the reasons for any delays in informing the campus community.
  8. Administer a survey to the laboratory Instructional Support Assistants and Technicians of each CSU campus to get a general overview of the health and safety climate at the campuses and to receive staff perspective on laboratory conditions and compliance with existing laws and regulations.
  9. Review and assess any other issues that are significant to the audit.