Maintain & Audit Business Continuity Plans

" Maintaining and Auditing a Business

Continuity Program-

A Plan for a Municipality"

February 12, 2011

by

Andrew M. Amalfitano

©AmalfiCORE, LLC Andrew M. Amalfitano 2/12/2011 pg. 2 of 17

CONTENTS

I. Introduction .....................................................................................................................................................................................3

II. Plan ......................................................................................................................................................................................................4

Key Plan Steps: ..............................................................................................................................................................................4

1. On-going .................................................................................................................................................................................4

2. Awareness and Launch ...................................................................................................................................................4

3. Implement .............................................................................................................................................................................5

4. Considerations ....................................................................................................................................................................5

III. Audit ..................................................................................................................................................................................................5

Standards ..........................................................................................................................................................................................6

Audit Elements ..............................................................................................................................................................................8

Process ...............................................................................................................................................................................................8

Identification of Individuals to be involved in the Audit ...................................................................................9

Functions to be Included in Audit ..................................................................................................................................9

Audit Approach .................................................................................................................................................................... 10

Documents to review .............................................................................................................................................................. 11

Audit Instrument ....................................................................................................................................................................... 12

Correcting Shortcomings....................................................................................................................................................... 12

III. Conclusion .................................................................................................................................................................................. 13

Appendix A - Continuity Assistance Tool (CAT) ............................................................................................................. 14

Appendix B: Plan Maintenance Example: National Center of State Courts ...................................................... 16

References .......................................................................................................................................................................................... 17


I. INTRODUCTION

A well developed, dusty plan sitting on a shelf does not ensure the City will be ready to weather

a major crisis or disaster. To really be ready, the City must maintain current plans, keep people

trained and informed, and exercise those plans on a periodic basis.

Scheduled, informal reviews1 and annual, independent audits2 are recommended and can

significantly improve the overall readiness of the City. Two plans in particular that must be

maintained in a current and effective condition are the Continuity of Operations Plan-COOP and

the Emergency Operations Plan-EOP.

Maintaining Continuity of Operations and Emergency Operation Plans can help ensure that the

City is ready for the unforeseen major crisis or disaster. This process includes the review,

testing, and update of the plans on a regular and defined schedule.

Audits may not always be necessary, however, due to their independent nature, are often a

valuable check and balance to internal plan reviews. Audits can objectively determine the

adequacy of controls and level of compliance to any appropriate standards.

This document describes how to maintain continuity plans, specifically the COOP and EOP. It

describes key plan steps, suggests self-assessment instruments, and makes a case of conducting

both internal reviews and external audits. It identifies the appropriate standards for the public

sector, describes the audit elements and process, who should be involved, functions and

documents to review, the audit approach, and how to manage shortcomings and make

improvements.

1 "REVIEW is the internal quality control process which looks for a practical and effective capability; it checks that nothing has

been overlooked; it reviews and assesses the past and considers the future; and it takes note of changing circumstances and makes recommendations where appropriate." [Burtles]

2 "AUDITING is the external process which looks for evidence of compliance with policy, prudence with finance, achievement of purposes and justification of claims." [Burtles]


II. PLAN

The fundamental plan for maintaining and auditing the continuity program at a municipality is

to follow the established testing, exercise, maintenance, and review process designated in the

COOP plan itself.

This process includes what to review, the frequency of review and update, who is responsible

for the review, and the criteria by which to determine the viability of the plan. A viable plan

exists when there is proof (through training, testing, and exercises) that the plan can be

implemented during a crisis or disaster and that the City's mission essential functions can be

continued successfully.

A comprehensive strategy for maintaining plans should inform the maintenance review and

audit planning process. For the public sector, the establishment of a Multi-Year Strategy and

Program Management Plan is recommended.3

KEY PLAN STEPS:

1. ON-GOING

a. Take actions to revise and update plan on a periodic cycle

b. Train new personnel and provide refresher training for others

c. Conduct periodic exercises, follow up with corrective actions from AAR4

d. Adhere to general COOP planning requirements

e. Identify issues that may impact the COOP and drive the frequency of changes

f. Identify the instrument(s) to be used to conduct the audit

g. Ensure there is adequate budget and funding for exercises and plan maintenance

2. AWARENESS AND LAUNCH

3 FEMA (2009) continuity assistance tool document. 4 FEMA (2007) http://training.fema.gov/EMIweb/edu/docs/TopOff4_afteraction_report2007.pdf

http://training.fema.gov/EMIweb/edu/docs/TopOff4_afteraction_report2007.pdf


a. Inform those involved

b. Get support and agreement from City functional directors

c. Designate a review team

d. Determine scope of the review or audit

• A description of elements that ensure a viable COOP capability.

• Identification of resources required to establish each element.

• Discussion of organization-specific management and policy issues.

e. Appoint and introduce the auditor as needed

3. IMPLEMENT

a. Begin the audit

b. Auditor meets with designated individuals, documents specific findings, uses the

identified instrument to score each function, and reports on findings.

4. CONSIDERATIONS

a. Final reporting of findings

b. Recommendations for plan maintenance improvements

c. Identification of deficiencies and opportunities for improvement

d. Commitment by City management to support, budget, rectify shortcomings by specific

dates

e. Scheduling of next audit

III. AUDIT A continuity audit is an evaluation of a the viability, at a point in time, of the COOP and

Emergency Operations in terms of people, the City as an organization, systems, processes, and

functions. The audit is conducted by an independent person or entity who will focus on the

business continuity and emergency operational readiness of the City based on the plan

components.


There are many benefits of a continuity audit at the City. The continuity audit can provide an

independent evaluation of the COOP and EOP plans and identify strengths and weakness of the

program. An audit can bring to light risks inherent in the plans and suggest strategies to reduce

or eliminate the risks. Finally, a thorough audit will report results that include

recommendations for improvements to the plans.

An audit of the emergency management/continuity of operations plans at the City will be done

in two phases. In the first phase, the Manager of the Office of Emergency Management will

coordinate period reviews, report on findings, and obtain budget and direction to make

improvements. Phase two will be an annual audit conducted by an independent person or

organization external to the City, that is, not an employee, vendors or supplier, or any person

directly affiliated with the city.

STANDARDS The most appropriate business continuity standards to follow for a municipality are those

applicable to the public sector: NFPA 1600, FPC-65, and FEMA COOP Guidelines.

NFPA 1600

The NFPA 1600 standard establishes "...a common set of criteria for all hazards

disaster/emergency management and business continuity programs". [NFPA 1600]

NFPA 1600 is a very relevant standard designed to "...apply to public, not-for profit, non-

governmental organizations (NGO), and private entities". [NFPA] The standard addresses

program improvement and provides a self-assessment tool which can serve as a valuable

means of performing a self-audit of the COOP plan. [NFPA]

FPC-65


The Federal Preparedness Circular-65, while designed for federal level agencies, suggests that

states and local government develop similar continuity of operations preparedness programs

that would align with the federal guidelines. As such, maintenance of the COOP should be part

of a multi-year strategy and program management plan. FPC-65 includes a definition of the 11

elements that agency COOP plans and programs must contain to be considered viable. When

auditing a COOP plan, each of these 11 elements should be evaluated and assessed". [US DHS-

audit forum 2007]

FEMA Continuity of Operations Plan Guidelines

The COOP training provided by FEMA is part of the Continuity Excellence series. One of the

fundamental aspects of the training describes the importance of testing, exercises, after action

reporting, corrective action and improvements. These elements constitute direction on how to

best keep updated plans, and maintain and improve agency readiness. [FEMA]

In addition, there are other standards that should be reviewed for their applicability to the

'business' of the City.

These may include the following:

Standard Applies to this Function

Department of Homeland Security and Federal Emergency Management Agency (DHS/FEMA), Federal Continuity Directive 1 and Federal Continuity Directive 2

COOP Plan

Health Insurance Portability and Accountability Act (HIPAA) – Regarding medical records protections

Human Resources

National Institute of Standards and Technology (NIST) – “Contingency Planning Guide for Information Technology Systems”.

Information Systems-IT

Federal Financial Institutions Examinations Council (FFIEC) Finance and Treasury

FEMA: National Response Framework-Incident Management System - ICS

Incident Management and Emergency Operations Plan

Figure 1: Additional Standards


AUDIT ELEMENTS An audit should cover a broad view of the continuity plan as well as a deep-dive into any details

that demand further inspection. Typically, a more detailed review is instigated by higher level

findings that elicit missing data, or are deemed inaccurate, incomplete, or suspect for any

reason.

Since a COOP plan includes all essential city functions, this is the only plan that needs to be

audited. However, given the criticality of emergency operations, it would be beneficial to

include the Emergency Operations Plan in an audit. Therefore, the plans to be reviewed and

audited should be:

Continuity of Operations Plan-COOP

Incident Management and Emergency Operations Plan-IC/EOP

PROCESS The audit process can be as simple or elaborate as desired, however, simpler and shorter in

duration is usually better.

The process begins with identification of those individuals to be involved with the review or

audit process. This may be an individual or a team, and in the case of an audit will usually be an

person external to the City.

The scope of the audit will identify which City functions, plans, and 'territory' will be audited.

The scope should be based on applicable standards and those functions represented in the

COOP or EOP plans. Any areas deemed outside of the plans should be excluded from the audit.

An approach to the audit should be established based on the goal of the audit. Since the goal of

most audits is to verify the existence of proof that a plan exists and is viable, then suitable

standards should be used for comparison. The types of questions should be identified early in

the process along with the instrument or tool to be used to score or rate the plans.


A list of plan elements, documents to review, and people to interview should be identified and

those involved should be notified in advance.

Conducting the audit should be bounded by time and scope with a description of expectations

of the auditor and all those involved. This requires good, clear communication of the intent and

purpose of the audit and expected outcomes.

Finally, there should be a pre-determined description of how the results will be reported, to

whom, and what action will be taken with those results. Where deficiencies are identified there

should be an openness to creating and implementing corrective actions, who will be

responsible, and in what time frame those improvements will be accomplished.

IDENTIFICATION OF INDIVIDUALS TO BE INVOLVED IN THE AUDIT

A formal, annual audit can be preceded by informal, more frequent reviews. The reviews should

include conversations with either the director of each city function or a person whom they

designate. During the formation of the COOP plan, each function identified a representative

who developed their portion of the plan. These individuals would be ideal interviewees for the

audit process, as well as, be involved in regular plan maintenance, testing and exercising of the

plan, and the review process. An audit of the EOP would best be conducted by another

qualified organization who also understands the nature of emergency operations. For this City,

the logical choice is the County Office of Emergency Management.

FUNCTIONS TO BE INCLUDED IN AUDIT

The following functions should be involved with the director of each function being responsible

for plan review and audit completion:

Office of the City Manager

Buildings & Facilities

Community Services

Finance

Human Resources


Information Technology

Light, Power, and Communications

Public Safety (Police, Fire, EMS, OEM, Emergency Communications)

Public Works

AUDIT APPROACH

The approach to conducting an audit should be supportive and positive with the intent of

identifying opportunities for improvement. The overall goal, of course, is for the City to be

operationally ready to continue mission essential functions during a crisis or disaster. The audit

should support that goal.

The City Manager's office should ensure that all departments and functions are made aware of

the value of an audit and set the expectation for full cooperation. Once awareness is

established, and an auditor is identified, the process should begin with a conversation and

interview from the top down. The directors of each function would first be interviewed

followed by a person whom they designate to represent their function. On some occasions the

auditor may go beyond these two people for each function depending on what is found during

the initial functional assessment.

A broad range of questions will yield an overall assessment of the general viability of the COOP

and Emergency Operations Plan.

At a high level, the following types of questions should be considered:

a. Does the COOP plan meet (as a guideline) the FPC-65 requirements?

b. Does the EOP plan meet (as a guideline) the NFPA 1600 requirements?

c. Do we find the specifics in each plan evident in reality? i.e. are the specifics

demonstrated by adequate funding, facilities, record keeping, systems integration,

trained and dedicated personnel, across all City functions?


d. Is there adequate oversight of the COOP and EOP plans to ensure completeness and

viability?

e. Are each of the 11 elements of the COOP plan reviewed and complete?

f. Are each of the 11 elements of the COOP plan tested and exercises at an appropriate

frequency?

g. Is there evidence of an After Action Report for each exercise and is there documentation

of corrective action follow up?

h. Does the electronic version of documentation exist, is it backed up adequately, and can

it be easily produced when asked?

i. Are plans and individual elements up to date

With these broad and high-level questions asked, the audit can proceed into more detail as

needed to gain a more full and accurate assessment of the current state of the COOP and EOP

plans.

DOCUMENTS TO REVIEW The key documents that should be kept up to date and reviewed periodically are those that

support the mission essential functions of each city function. For the EOP, the entire plan

including annexes and appendices should be included.

All 11 elements of the COOP plan may have documents and if so, all of these documents should

be reviewed. In any case, the minimum document review list should be:

Mission Essential Functions

Key personnel contact information

Information System codes, software, keys, passwords

Vital records and data files

Critical vendor and supplier contact information

Building access and security documents


Plans: Continuity of Operations-COOP, Emergency Operations-EOP, Continuity of

Government

AUDIT INSTRUMENT The NFPA 1600 standard offers a suggested self-assessment instrument/tool which can be used

by the City to perform a quick evaluation of the conformity to requirements of the COOP and

EOP plans. That instrument can be found in the table labeled Table C.1. of Annex C of the NFPA

1600 standard. The tool allows indication of "conformity, partial conformity, or nonconformity

as well as indicate evidence of conformity, corrective action, task assignment, a schedule for

action, or other information in the Comments column." [NFPA 1600 Annex C]

In addition to the NFPA tool, FEMA offers a Continuity Assistance Tool-CAT. The CAT tool

provides a way to identify the strengths and weaknesses of the City continuity plan and show

areas that need improvement. See Appendix 'A' for more details.

CORRECTING SHORTCOMINGS Any review or audit process will elicit the identification of strengths and weaknesses or

shortcomings. These shortcomings should be well documented with clear and concise

recommendations of what actions should be taken to make improvements. Vague

generalizations are not useful and should be avoided.

As part of the steering of the review or audit, the City Manager's office should get agreement

with the functional directors as to who the audience is to hear and consider the findings and

take actions. As a municipality, ultimately any citizen should be able to have visibility to the

results and actions being taken to mitigate and improve the COOP and EOP plans based on the

review or audit findings.


A project plan approach should be used to track and demonstrate that improvements have

been implemented. Typical tracking will include a set of numbered actions, with a description of

what 'complete' looks like, the name of the person responsible for seeing that the improvement

is completed and an agreed to time frame or due date.

III. CONCLUSION

This document presents a plan for maintaining the COOP and EOP plans of the City. A case is

made of the benefits of conducting both a periodic internal review and an annual independent

audit. A plan is proposed with key actions to be taken along with a description of the elements

and approach of an audit.

The municipality as a public entity should conform with established standards from government

entities, namely FEMA continuity guidelines, NFPA 1600 and others pertinent directives.

The use of suggested evaluation instruments can help bring consistency to a self-assessment

and provide for a repeatable process. The document establishes the need for transparency of

the findings and urges prompt and coordinated actions to fix shortcomings and institute

improvements.

The end result of a proper maintenance plan and audit program will be a higher degree of

assurance that the city is ready to continue mission essential functions during a crisis or

disaster. This assurance can only come from a systematic and documented approach to plan

maintenance that demonstrates accountability through specific actions.


APPENDIX A - CONTINUITY ASSISTANCE TOOL (CAT)5

FEMA provides a tool to help public sector organizations like the City to perform a self-

evaluation of their continuity programs.

"CAT PROCESS

The process provided below is the recommended method to apply this tool:

Step 1: The continuity manager meets with functional representatives (i.e., IT manager, HR

manager, Security managers, etc.) of the organization to review the CAT.

Step 2: With the assistance of the continuity manager, the functional representatives review

their respective characteristics.

Answer each characteristic “Yes”, “No”, or “Not Applicable” (N/A). Flexibility is built into

the assistance tool. Therefore, “Not Applicable” (N/A) may be used for those

characteristics that do not apply.

Step 3: For each characteristic, a “comments” section is provided to enter any helpful notes.

Step 4: For each CMF, tally all Characteristics to obtain the “Yes”, “No”, and “N/A” CMF totals.

Record this tally in the CMF header.

Step 5: Capture each CMF total in Table 2 - Continuity Management Functions Summary on

page ix."

Example: Excerpt from CAT self-assessment tool 1.6.3.

6 Has the organization developed and maintained a vital records plan packet or

collection that list records recovery experts or vendors? [CGC 1 Annex I, Page I-3]

Yes No N/A

Comments: 1.6.3.

7 Has the organization developed and maintained a vital records plan packet or

collection that includes a copy of the organization’s continuity plans? [CGC 1 Annex I, Page I-3]

Yes No N/A

Comments: 1.6.3.

8 Has the organization reviewed its vital records plan packet or collection within

the past year with the date and names of the personnel who conducted the review documented in writing to ensure that the information is current and

with a copy of the review maintained at the organization’s alternate facility?

[CGC 1 Annex I, Page I-3]

Yes No N/A

5 FEMA Continuity Assistance Tool (2009)


Figure 2: FEMA Continuity Assistance Tool scoring table


APPENDIX B: PLAN MAINTENANCE EXAMPLE: NATIONAL CENTER

OF STATE COURTS

"PLAN MAINTENANCE: The management process of keeping an organization’s Business continuity

management plans up to date and effective. Maintenance procedures are a part of this process for

the review and update of the BC plans on a defined schedule. Maintenance procedures are a part of

this process. "6

Action Tasks Responsible Position

Frequency

Update and certify the

Plan

Review entire plan for accuracy

Incorporate lessons learned from real-life activations of the plan and from testing and exercises

Incorporate changes in policy and philosophy

Manage distribution

[Name/

Position

responsible]

Annually

Maintain and update

Orders of Succession

and Delegations of

Authority

Obtain current incumbents

Update rosters and contact information

[Name/

Position]

Semi-Annually

Revise checklists and

contact information for

Emergency Relocation

Team members

Update and revise checklists

Confirm/update information for members of the Emergency Relocation Team

All Court

Offices

Annually

Appoint new members to

the Emergency

Relocation Team

Train new members on their responsibilities

Integrate new members into team training

[Name/

Position]

As needed

Maintain alternate

facility readiness

Check all systems

Verify accessibility

Cycle supplies and equipment, as necessary

[Name/

Position]

Monthly

Monitor and maintain

vital records

management program

Monitor volume of materials

Assist court staff with updating/removing files

All Court

Offices

Ongoing

Train new court staff Include in new employee orientation [Name Position] Within 30 days

of appointment

Orient new policy

officials and senior

leadership

Brief officials on existence and concepts of the COOP plan

Brief officials on their responsibilities under the COOP plan

[Name Position] Within 30 days

of appointment

Plan and conduct

exercises

Conduct internal COOP exercises

Conduct joint exercises with other courts

Conduct joint exercises with judges and staff

[Name Position] Semi-annually

As needed

6 National Center for State Courts, (2007).


REFERENCES Beard, Mike, (2010). "Adding Value to the Enterprise Through Operational Project Auditing". Institute of Internal Auditors.

Retrieved 2-11-11. http://www.vbpm.org/home/wp-content/uploads/2010/08/Ops-n-Project-Auditing-IIA-Beach-Cities-2010009.pdf

Burtles, Jim, (2007). "Principles and Practices of Business Continuity- Tools and Techniques". Chapter 12. Rothstein Associates,

Connecticut Crowe, Timothy, J. (2010). "Evaluating Continuity of Operations Plans and Programs". Virginia US Department of Veterans

Affairs/Office of Inspector General. Retrieved 2-12-11: http://www.floridaauditforum.org/files/meeting/2010_02/Crowe_Evaluating%20COOPs.pdf

DHS-FEMA, (2004). "Federal Preparedness Circular, FPC-65". Retrieved 2-11-11:

http://www.fema.gov/pdf/library/fpc65_0604.pdf FEMA, (2009). "Train the Trainer Instructor Guide E/L 550". Continuity Planners Workshop. Chapter 7 Corrective Action

Planning FEMA, (2009). "Continuity Assistance Tool (CAT)- Continuity Assistance for Non-Federal Entities (States, Territories, Tribal, and

Local Government Jurisdictions and Private Sector Organizations)". Retrieved 2-11-11: http://www.fema.gov/pdf/about/org/ncp/cat.pdf

Hiles, A. (Ed.). (2007). The Definitive Handbook of Business Continuity Management. 2nd Edition. England: John Wiley & Sons National Center for State Courts, (2007). "A Comprehensive Emergency Management Program-Part III, Appendix A". NFPA, (2010). "NFPA 1600 Standard on Disaster/Emergency Management and Business Continuity Programs 2010 Edition:

Annex C Self Assessment for Conformity with NFPA 1600 2010 Edition". Retrieved 2-1-11: http://www.nfpa.org/assets/files/PDF/NFPA16002010.pdf

North Carolina Emergency Management, (2006). "North Carolina Continuity of Operations Planning Manual". 2nd Edition.

Retrieved 2-1-11: http://www.nccrimecontrol.org/div/em/documents/COOPPlannin%20Manua%202ed.pdf Office of Emergency Management, Boulder County Colorado, (2009). "EOP Plan", pg 67. Retrieved 2-11-11:

http://www.boulderoem.com/files/Boulder%20-%20BEOP%205-5-09.pdf Texas Dept. of State Health, (2008). "Pandemic Influenza Annex to the Continuity of Operations (COOP) Plan". Retrieved 2-8-11:

http://www.dshs.state.tx.us/comprep/pandemic/Pandemic%20Influenza%20Annex_%20DSHS%20Agency%20Level%20COOP%20Plan.pdf

US Dept. Homeland Security, (May 2007). "Evaluating Continuity of Operations Programs-Approaches & Case Study".

NY/NJ/IGAF Conference. Retrieved 2-9-11: http://www.auditforum.org/speaker%20presentations/nynj/nynjiaf%2005%202007/crowe.pdf

Wold, Geoffrey, (2010). "How to Survive a BCM Audit". Disaster Recovery Journal. Retrieved 2-8-11: http://www.drj.com/2010-

articles/summer-2010/how-to-survive-a-bcm-audit.html

End of Document

http://www.vbpm.org/home/wp-content/uploads/2010/08/Ops-n-Project-Auditing-IIA-Beach-Cities-2010009.pdf

http://www.vbpm.org/home/wp-content/uploads/2010/08/Ops-n-Project-Auditing-IIA-Beach-Cities-2010009.pdf

http://www.floridaauditforum.org/files/meeting/2010_02/Crowe_Evaluating%20COOPs.pdf

http://www.fema.gov/pdf/library/fpc65_0604.pdf

http://www.fema.gov/pdf/about/org/ncp/cat.pdf

http://www.nfpa.org/assets/files/PDF/NFPA16002010.pdf

http://www.nccrimecontrol.org/div/em/documents/COOPPlannin%20Manua%202ed.pdf

http://www.boulderoem.com/files/Boulder%20-%20BEOP%205-5-09.pdf



http://www.auditforum.org/speaker%20presentations/nynj/nynjiaf%2005%202007/crowe.pdf

http://www.drj.com/2010-articles/summer-2010/how-to-survive-a-bcm-audit.html

http://www.drj.com/2010-articles/summer-2010/how-to-survive-a-bcm-audit.html

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