Maintain & Audit Business Continuity Plans

" Maintaining and Auditing a Business
Continuity Program-
A Plan for a Municipality"

February 12, 2011
by

Andrew M. Amalfitano

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

©AmalfiCORE, LLC Andrew M. Amalfitano 2/12/2011 pg. 2 of 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 audits 2 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 AAR 4
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


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 COOP Plan
Management Agency (DHS/FEMA), Federal Continuity
Directive 1 and Federal Continuity Directive 2
Health Insurance Portability and Accountability Act (HIPAA) Human Resources
– Regarding medical records protections
National Institute of Standards and Technology (NIST) – Information Systems-IT
“Contingency Planning Guide for Information Technology
Systems”.
Federal Financial Institutions Examinations Council (FFIEC) Finance and Treasury
FEMA: National Response Framework-Incident Management Incident Management and
System - ICS 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. Has the organization developed and maintained a vital records plan packet or Yes No N/A
6 collection that list records recovery experts or vendors? [CGC 1 Annex I, Page
I-3]
Comments:
1.6.3. Has the organization developed and maintained a vital records plan packet or Yes No N/A
7 collection that includes a copy of the organization’s continuity plans? [CGC 1
Annex I, Page I-3]
Comments:
1.6.3. Has the organization reviewed its vital records plan packet or collection within Yes No N/A
8 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]

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 Frequency
Position

Update and certify the  Review entire plan for accuracy [Name/ Annually
Plan  Incorporate lessons learned from real-life activations of the Position
plan and from testing and exercises responsible]
 Incorporate changes in policy and philosophy
 Manage distribution
Maintain and update  Obtain current incumbents [Name/ Semi-Annually
Orders of Succession  Update rosters and contact information Position]
and Delegations of
Authority
Revise checklists and  Update and revise checklists All Court Annually
contact information for  Confirm/update information for members of the Emergency Offices
Relocation Team
Emergency Relocation
Team members
Appoint new members to  Train new members on their responsibilities [Name/ As needed
the Emergency  Integrate new members into team training Position]
Relocation Team
Maintain alternate  Check all systems [Name/ Monthly
facility readiness  Verify accessibility Position]
 Cycle supplies and equipment, as necessary
Monitor and maintain  Monitor volume of materials All Court Ongoing
vital records  Assist court staff with updating/removing files Offices
management program
Train new court staff  Include in new employee orientation [Name Position] Within 30 days
of appointment
Orient new policy  Brief officials on existence and concepts of the COOP plan [Name Position] Within 30 days
officials and senior  Brief officials on their responsibilities under the COOP plan of appointment
leadership
Plan and conduct  Conduct internal COOP exercises [Name Position] Semi-annually
exercises  Conduct joint exercises with other courts As needed
 Conduct joint exercises with judges and staff

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%20C
OOP%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


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