” Maintaining and Auditing a Business Continuity Program-
A Plan for a Municipality“
February 12, 2011
Andrew M. Amalfitano
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
Audit Elements. 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
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 reviews and annual, independent audits 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.
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.
Key Plan Steps:
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 AAR
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
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
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.
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
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.
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]
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:
||Applies to this Function
|Department of Homeland Security and Federal Emergency Management Agency (DHS/FEMA), Federal Continuity Directive 1 and Federal Continuity Directive 2
|Health Insurance Portability and Accountability Act (HIPAA) – Regarding medical records protections
|National Institute of Standards and Technology (NIST) – “Contingency Planning Guide for Information Technology Systems”.
|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
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
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
§ Human Resources
§ Information Technology
§ Light, Power, and Communications
§ Public Safety (Police, Fire, EMS, OEM, Emergency Communications)
§ Public Works
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
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.
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.
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)
FEMA provides a tool to help public sector organizations like the City to perform a self-evaluation of their continuity programs.
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
||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]
||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]
||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]
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. “
|Update and certify the
| 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
|[Name/ Position responsible]
|Maintain and update
Orders of Succession
and Delegations of
| Obtain current incumbents
Update rosters and contact information
|Revise checklists and
contact information for
| Update and revise checklists
Confirm/update information for members of the Emergency Relocation Team
|Appoint new members to
| Train new members on their responsibilities
Integrate new members into team training
| Check all systems
Cycle supplies and equipment, as necessary
|Monitor and maintain
| Monitor volume of materials
Assist court staff with updating/removing files
|Train new court staff
|| Include in new employee orientation
||Within 30 days
|Orient new policy
officials and senior
| Brief officials on existence and concepts of the COOP plan
Brief officials on their responsibilities under the COOP plan
||Within 30 days
|Plan and conduct
| Conduct internal COOP exercises
Conduct joint exercises with other courts
Conduct joint exercises with judges and staff
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
“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]
 “AUDITING is the external process which looks for evidence of compliance with policy, prudence with finance, achievement of purposes and justification of claims.” [Burtles]
 FEMA (2009) continuity assistance tool document.
 FEMA (2007) http://training.fema.gov/EMIweb/edu/docs/TopOff4_afteraction_report2007.pdf
 FEMA Continuity Assistance Tool (2009)
 National Center for State Courts, (2007).