ESSG SRA Audit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Introduction

• How long have you been in business?

• Does any single account make up more than 25% of your business

  Yes

  No

  N/A

• What type of operation (include NCCI code)?

• Are you currently involved in any secondary supplier relationships?

  Yes

  No

  N/A

• explain

• Do you provide group transportation for employees?

  Yes

  No

  N/A

• explain in detail (number of employees, drivers, etc.)

• Is there a full time Risk Manager?

  Yes

  No

  N/A

• Explain any addition job responsibilities (HR, Benefits, Sales)

• Describe job duties and experience

• What are the plans for handling risk management

• Is there a person actively visit all branch locations regularly to assure compliance with risk management policies and procedures?

  Yes

  No

  N/A

• Is there a person actively involved in the training process at all levels (development of materials, oversight of process, internal training for full time staff, etc.)?

  Yes

  No

  N/A

• Is there a person oversee the Doctor/Clinic relationship and modified duty programs?

  Yes

  No

  N/A

• Name of person involved with claims management issues?

• Is this person open to assistance from carrier loss control representatives, including client

Branch Office

• Are facilities neat and professional in appearance?

  Yes

  No

  N/A

• Are all required regulatory posters (OSHA, WC, DOL, etc.) prominently displayed in an area highly visible to all applicants?

  Yes

  No

  N/A

• Is evidence of substance abuse policy prominently displayed in an area highly visible to all applicants, or in advertisements/publications or website for electronic applications?

  Yes

  No

  N/A

• Are workers comp fraud posters prominently displayed in an area highly visible to all applicants?

  Yes

  No

  N/A

• Are safety posters prominently displayed in an area highly visible to applicants?

  Yes

  No

  N/A

Pre-Employment Phase

• Is the branch office using the current approved version of the (Client Name) Staffing Application?

  Yes

  No

  N/A

• (Applicant Phone Inquiries) Are screening questions regarding consent for drug testing and background history inclusive of criminal records asked of all applicant phone inquiries?

  Never

  Sometimes

  Often

  Always

  NA

• Are applicant questionnaires regarding consent for drug testing and background history inclusive of criminal records conducted and documented for all in person applicant inquiries?

  Never

  Sometimes

  Often

  Always

  NA

• Are applicant questionnaires signed by applicant?

  Yes

  No

  N/A

• Is a file kept of all negative applicant questionnaires?

  Yes

  No

  N/A

Personnel Records

• Are all applications/employment contracts signed by applicants?

  Never

  Sometimes

  Often

  Always

  NA

• Are all blanks and/or questions on the applications/employment completed

  Yes

  No

  N/A

• Do personnel files contain completed and signed drug consent and criminal records release?

  Yes

  No

  N/A

• Are all medical related records kept in a "need-to-know" file separate from personnel files?

  Yes

  No

  N/A

Interview/ Employee Selection

• Are steps taken to insure that no medical or health related questions are asked during the application phase?

  Yes

  No

  N/A

• During the interview, are applications thoroughly scrutinized to detect discrepancies and identify red flags?

  Never

  Sometimes

  Often

  Always

  NA

• Are predator applicants identified and the information shared with those who have a need to know?

  Never

  Sometimes

  Often

  Always

  NA

• Are references and experience verified, as well as applicable certifications and/or licenses?

  Never

  Sometimes

  Often

  Always

  NA

• Is there a computer database that provides for sharing of information between offices? At what point is the applicant information put into the database?

Orientation

• Are all employees informed of the staffing service's W/C philosophy via WC Mission Statement or similar communication?

  Never

  Sometimes

  Often

  Always

  NA

• Is the policy & procedures checklist reviewed with the applicant and signed by the interviewer and the applicant?

  Never

  Sometimes

  Often

  Always

  NA

• Are accident/injury policies thoroughly reviewed with all employees during orientations?

  Never

  Sometimes

  Often

  Always

  NA

• Does the time sheet, signoff, or record of time submitted include the "No Accident/No Injury" statement and are employees informed during orientations?

  Yes

  No

  N/A

• Is a mechanism in place to promote employee safety suggestions and is this communicated during orientations?

  Yes

  No

  N/A

• Do all employees view the safety orientation video or complete an equivalent safety orientation, take the accompanying test, and is this documented?

  Never

  Sometimes

  Often

  Always

  NA

• How long does your orientation process normally take?

Client Safety Programs

• Are assignments reviewed for appropriate ergonomic design?

  Never

  Sometimes

  Often

  Always

  NA

• Are clients informed of the staffing service's safety and loss control philosophies?

  Never

  Sometimes

  Often

  Always

  NA

• Are client safety partnership letters or similar documentation reviewed and signed by client?

  Never

  Sometimes

  Often

  Always

  NA

• Are hold harmless or applicable indemnification agreements utilized?

  Yes

  No

  N/A

• Are clients informed of the accident/injury procedures of the company?

  Never

  Sometimes

  Often

  Always

  NA

• Are clients notified of the findings of the safety evaluations?

  Yes

  No

  N/A

• Do employees receive site/assignment safety training from clients and does (Client Name) retain documentation in the form of client-provided documents, or use of Verification of Emoployee Training form, or equivalent?

  Never

  Sometimes

  Often

  Always

  NA

• Are employees informed and/or trained regarding safety issues on a monthly basis, and is this documented?

  Never

  Sometimes

  Often

  Always

  NA

• Does staffing service provide PPE to employees and if so, is proper training conducted and documented?

  Never

  Sometimes

  Often

  Always

  NA

• Are client onsite safety evaluations conducted and documented prior to service via Client Facility Evaluation?

  Never

  Sometimes

  Often

  Always

  NA

• Are follow-up client onsite safety evaluation conducted every 90 days and documented via Client Facility Evaluation?

  Never

  Sometimes

  Often

  Always

  NA

• Who conducts these evaluations?

• What is their level of training pertaining to workplace safety?

Accident / Injury Investigations

• Does branch have Employee Injury Kits available and assembled for immediate use?

  Never

  Sometimes

  Often

  Always

  NA

• Is there a pre-established doctor/clinic relationship?

  Yes

  No

  N/A

• Are injured employees transported to the treating facility by the staffing service or staffing service's representative?

  Never

  Sometimes

  Often

  Always

  NA

• Is the staffing service or staffing service's representative in attendance with the injured employee at the treating facility?

  Never

  Sometimes

  Often

  Always

  NA

• Is drug testing conducted for all accidents/injuries?

  Never

  Sometimes

  Often

  Always

  NA

• Does the staffing service conduct an on-site investigation for all accidents/injuries and are corrective measures taken?

  Never

  Sometimes

  Often

  Always

  NA

• Are all incidents/injuries thoroughly investigated, including onsite when possible, and are corrective measures identified and communicated to clients?

  Never

  Sometimes

  Often

  Always

  NA

• Who conducts the investigations?

• What determines the timelines of the investigation (immediate vs. delayed?

Modified Duty Program

• Are treating physicians knowledgeable of accommodating modified duty?

  Never

  Sometimes

  Often

  Always

  NA

• Does the staffing service provide accommodating modified duty for all injured employees upon receipt of a doctor's release for modified duty?

  Never

  Sometimes

  Often

  Always

  NA

• Are modified duty assignments effective in returning employees to regular work duties?

  Never

  Sometimes

  Often

  Always

  NA

• Is notice of modified duty sent to the injured employee via certified and regular mail, or Acknowledgment of Modified Duty signed by the injured employee?

  Never

  Sometimes

  Often

  Always

  NA

Claims Management

• Does the staffing service have a qualified individual (staff or contract) designated to handle claims?

  Yes

  No

  N/A

• Is there a working knowledge of state workers compensation laws/requirements/procedures?

  Yes

  No

  N/A

• Are all claims reported in a timely manner, within 24 hours, or as required by the state and/or carrier/TPA?

  Never

  Sometimes

  Often

  Always

  NA

• Is there a clear understanding of the claims reporting procedures and requirements?

  Yes

  No

  N/A

• Are claimants with full restrictions, not released for modified duty, contacted at least weekly and is this contact documented?

  Never

  Sometimes

  Often

  Always

  NA

• Does the staffing service have an active relationship with carrier/TPA claims adjuster(s) and/or the Staffing Service Risk Manager?

  Yes

  No

  N/A

• Is a monthly analysis of claims conducted via the staffing service accident log and/or the carrier/TPA loss runs?

  Yes

  No

  N/A

• Is a regular follow-up of open claims regarding treatment plans and release to work conducted and verified by documentation with the carrier/TPA representative and/or the Staffing Service Risk Manager?

  Never

  Sometimes

  Often

  Always

  NA

• Are claim reviews conducted and verified by documentation with carrier/TPA via phone and/or meeting on at least a quarterly basis?

  Yes

  No

  N/A

• Are private investigators used when necessary?

  Never

  Sometimes

  Often

  Always

  NA

• Is an accident/injury log maintained and monitored at each office to facilitate a working knowledge of accidents/injuries to identify trends, frequency, and types of accidents?

  Never

  Sometimes

  Often

  Always

  NA

Miscellaneous

• Does the staffing service provide and document risk management/loss control training for full time staff?

  Never

  Sometimes

  Often

  Always

  NA

• What is the nature of the training?

• Who conducts/oversees the training?

• Is there accountability for operational compliance of risk management for full time staff?

  Yes

  No

  N/A

• Are staffing service risk management meetings conducted and documented at least quarterly?

  Yes

  No

  N/A

• Who is responsible for assigning workers compensation codes?

• What is the methodology for assignment of codes (NCCI Scopes, online services, etc.)?

• Is documentation of staff risk management meetings communicated to all staff?

  Never

  Sometimes

  Often

  Always

  NA

• Is there an absence of unacceptable workers compensation class codes?

  Yes

  No

  N/A

• Is there accurate assignment of workers compensation classification codes and is this procedure verified?

  Yes

  No

  N/A

Comments

• Comment on prospect's overall attitude toward workplace safety and risk management.