Internal Audit Report

Audit of the Canadian Shellfish Sanitation Program

Project 6B281
Date: June 9, 2017


TABLE OF CONTENTS



1.0 EXECUTIVE SUMMARY

The objective of this audit was to provide reasonable assurance that governance, risk management and control processes in place are adequate and working effectively to ensure that the Department of Fisheries and Oceans Canada (DFO) is able to deliver on its program requirements under the Canadian Shellfish Sanitation Program (CSSP). The scope of this audit included the DFO CSSP governance and control environment; financial and human resource management; risk management; and communication and information management.

The audit was carried out in National Headquarters, and included one site visit to the Gulf region, with additional regional interviews conducted by teleconference across all DFO CSSP regions (Pacific, Quebec, Maritimes, Gulf and Newfoundland and Labrador). The audit focused on DFO’s role in program delivery and did not cover the portions of the program delivered by DFO’s CSSP partners.

Why This is Important

The Canadian Shellfish Sanitation Program (CSSP) is a federal food safety program jointly administered by Fisheries and Oceans Canada (DFO), the Canadian Food Inspection Agency (CFIA) and Environment and Climate Change Canada (ECCC). The goal of the program is to protect Canadians from the health risks associated with the consumption of contaminated bivalve molluscan shellfish, such as mussels, oysters and clams. Under the CSSP, the Government of Canada implements controls to verify that only shellfish that meet food safety and quality standards reach domestic and international markets. DFO is responsible for ensuring that bivalve molluscan shellfish are harvested from approved areas under the authorities of the Fisheries Act and the Management of Contaminated Fisheries Regulations.

Key Findings

The audit found that there are opportunities for improvement in terms of the Department’s CSSP governance. While an interdepartmental governance committee structure exists, there is no internal DFO CSSP governance committee structure in place to share information and discuss DFO CSSP issues with key representatives from all regions. In addition, there are opportunities for improvement with regard to DFO’s program delivery. The audit found that the program lacks a national program framework including policies and guidelines to ensure consistent implementation of program activities across all regions.

Improvements are also required to ensure the reliability, accuracy and consistency of CSSP shellfish harvesting information. The audit found incomplete shellfish harvesting and patrol data to support CSSP decision making. Also, while some monitoring of CSSP resources is taking place, the Department lacks adequate information on its financial and human resource allocations to ensure that it can fulfill its responsibilities under the CSSP interdepartmental Memorandum of Understanding (MOU).

Conclusion

Based on the audit work conducted, improvements to the current governance, risk management and control processes in place are needed to ensure they are adequate and working effectively, in order for DFO to meet its CSSP program delivery requirements. Specifically, the audit found that there is a need to strengthen DFO CSSP governance committee structure, reporting structure and national consistency, as well as, improve the reliability, accuracy and consistency of CSSP information. Opportunities exist to enhance existing practices and to strengthen the adequacy and effectiveness of internal controls, particularly in the areas of standard operating procedures and financial and human resource management.

Management Response

Management is in agreement with the audit findings, has accepted the recommendations included in this report, and has developed a management action plan to address them. The management action plan has been integrated in this report.

Approvals

The internal audit report for the Audit of the Canadian Shellfish Sanitation Program was presented at the Departmental Audit Committee on June 9, 2017. The Report was recommended for approval by the Departmental Audit Committee and approved by the Deputy Minister.

2.0 BACKGROUND

The Canadian Shellfish Sanitation Program (CSSP or the program) is a federal food safety program jointly administered by Fisheries and Oceans Canada (DFO), the Canadian Food Inspection Agency (CFIA) and Environment and Climate Change Canada (ECCC). The goal of the program is to protect Canadians from the health risks associated with the consumption of contaminated bivalve molluscan shellfish, such as mussels, oysters and clams. Eating contaminated shellfish can cause potentially serious or fatal illness. Human and animal wastes are rich in bacteria and enter shellfish areas from several land-based pollution sources, including municipal wastewater treatment plants, poorly-maintained septic systems and run-off from agricultural areas, as well as sea-based sources such as boats and wildlife. Under the CSSP, the Government of Canada implements controls to verify that only shellfish that meet food safety and quality standards reach domestic and international markets.

The CFIA is the lead agency for the CSSP and is responsible for the control of handling, storage, transportation, processing and labelling of shellfish, including imports; the Marine Biotoxins Control Program; and liaising with foreign governments on matters relevant to shellfish sanitation. Although led by CFIA, the three partner departments work collectively to achieve the program’s objectives of minimizing health risks from the consumption of contaminated bivalve molluscan shellfish and fulfilling Canada’s international obligations to meet the terms of bilateral agreements and standards. ECCC is responsible for the monitoring of water quality in shellfish areas, for the identification and evaluation of pollution sources and for the recommendations of the classification of shellfish harvesting areas on the basis of growing water surveys. DFO is responsible for ensuring that bivalve molluscan shellfish are harvested from approved areas. The authorities under which DFO participates in the CSSP flow from the Fisheries Act and the Management of Contaminated Fisheries Regulations.

Within DFO’s Ecosystems and Fisheries Management Sector, the Aquaculture Management Directorate is the DFO lead for the CSSP, while Conservation and Protection (C&P) is responsible for compliance and enforcement activities. The requirements for each partner department of the program are outlined in the interdepartmental CSSP Memorandum of Understanding (MOU) and Manual of Operations. The first CSSP MOU was signed in 1990 between Environment Canada (now ECCC) and DFO and was revised in 2000 to reflect the transfer of fish inspection activities from DFO to the then newly created CFIA. As per the interdepartmental CSSP MOU issued in 2000, DFO’s key responsibilities include: opening and closing shellfish areas; posting the closure signs in harvesting areas, patrolling and enforcing shellfish closures in accordance with the Fisheries Act; controlling shellfish relaying operations and harvesting for depuration operations; implementing DFO portions of jointly developed Management Plans for “Conditionally Approved” areas; and providing information to stakeholders on opening and closures of shellfish areas.

Within DFO, the program resides in the Aquaculture Management Directorate, due in part to the increased demand from the aquaculture sector for the development of additional shellfish growing sites under CSSP. For example, the federal government’s advisory council 2017 report on economic growth, ‘Unleash the Growth Potential of Key Sectors,’Footnote 1 notes opportunities to enhance and grow the aquaculture industry. As such, DFO CSSP management is currently working on a Long-Term Sustainability Work Plan to address CSSP resource constraints and continued economic growth pressures, while maintaining health protection. The Long-Term Sustainability Work Plan is comprised of the following four pillars:

  1. Pillar 1: Online interactive mapping tool to communicate where bivalve shellfish can safely be harvested;
  2.  
  3. Pillar 2: Review of shellfish harvest areas to align resources where they are most needed to protect public health and maintain market access;
  4.  
  5. Pillar 3: Explore alternate delivery options for commercial harvest (wild commercial and aquaculture fisheries), allowing the sector to maintain food safety and market access; and
  6.  
  7. Pillar 4: Explore alternate delivery options maintaining equivalent health protection outcomes for non- commercial harvest (recreational and food, social and ceremonial (FSC) fisheries).

3.0 AUDIT OBJECTIVE

The objective of this audit was to provide reasonable assurance that governance, risk management and control processes in place are adequate to ensure that the Department of Fisheries and Oceans Canada (DFO) is able to deliver on its program requirements under the Canadian Shellfish Sanitation Program (CSSP).

4.0 AUDIT SCOPE

The scope of this audit included the DFO CSSP governance and control environment; financial and human resource management; risk management; and communication and information management. The audit was primarily carried out in National Headquarters (NHQ), and included one site visit to the Gulf region, as this DFO region includes three Atlantic provinces with significant shellfish harvesting activity (New Brunswick, Prince Edward Island and Nova Scotia). Additional regional interviews were conducted by teleconference across all DFO CSSP regions (Pacific, Quebec, Maritimes, Gulf and Newfoundland and Labrador). The audit focused on DFO’s role in program delivery and did not cover the portions of the program delivered by DFO’s CSSP partners.

5.0 AUDIT APPROACH

The audit team carried out its mandate in accordance with Treasury Board’s Policy on Internal Audit and the Internal Audit Standards for the Government of Canada and the Institute of Internal Auditors’ International Standards for the Professional Practice of Internal Auditing. These standards require that the engagement be planned and performed in such a way as to obtain reasonable assurance that the objective of the engagement is achieved. The audit employed various techniques including a risk assessment of the audit entity, interviews, as well as analysis of the documentation and information gathered. A detailed examination of each of DFO’s responsibilities identified within the MOU, including the related DFO operating procedures from the CSSP Manual of Operations, was conducted to provide assurance that the department is fulfilling its obligations as per the MOU. The audit also examined a sample of prohibition orders and conditional management plans selected from fiscal year 2015-16 for file review and analysis.

6.0 AUDIT FINDINGS

This section provides the observations and recommendations resulting from the audit work carried out. While the audit was conducted based on the lines of enquiry and audit criteria identified in the planning phase (see Appendix A), this report is structured along the following main themes:

  • Governance and Control Environment;
  • Information for decision making; and
  • Financial and Human Resources Management.

Based on the audit work performed and our professional judgment, the risk associated with each observation was rated using a three-point scale. The risk ranking (high, moderate, low) is based on the level of potential risk exposure we feel may have an impact on the achievement of Fisheries and Oceans Canada objectives, and is indicative of the priority Management should give to the recommendations associated with that observation. The following criteria were used in determining the risk exposure:


Table 1: Risk ranking criteria
HighControls are not in place or are inadequate.
HighCompliance with legislation and regulations is inadequate.
HighImportant issues are identified that could negatively impact the achievement of program/operational objectives.
ModerateControls are in place but are not being sufficiently complied with.
ModerateCompliance with central agency/departmental policies and established procedures is inadequate.
ModerateIssues are identified that could negatively impact the efficiency and effectiveness of operations.
LowControls are in place but the level of compliance varies.
LowCompliance with central agency/departmental policies and established procedures varies.
LowIssues identified are less significant but opportunities that could enhance operations exist.

6.1 GOVERNANCE AND CONTROL ENVIRONMENT (MODERATE RISK)

Governance is the combination of processes and structures implemented to inform, direct, manage, and monitor the activities of the organization toward the achievement of its objectives.Footnote 2 Governance contributes to the strategic direction, oversight, decision-making, and accountability for an organization to successfully meet its objectives. Policies, procedures, and tools support effective program design and delivery when they are established, maintained and communicated effectively. Management obtains or generates and uses relevant and quality information from both internal and external sources for the entity to carry out internal control responsibilities to support the achievement of its objectives.

Governance and oversight bodies

We expected that departmental governance and oversight bodies for the CSSP would be established and operating effectively to ensure that DFO is able to fulfill its CSSP responsibilities.

Departmental CSSP governance needs improvement in terms of committee representation, reporting structure and regional consistency

 

Governance and oversight bodies
We expected that departmental governance and oversight bodies for the CSSP would be established and operating effectively to ensure that DFO is able to fulfill its CSSP responsibilities.

 

Departmental CSSP governance needs improvement in terms of committee representation, reporting structure and regional consistency

 

At the interdepartmental level, overall governance for the program is established via a suite of interdepartmental committees comprised of NHQ and regional membership from all three partner departments. These committees include the Assistant Deputy Minister (ADM) Steering Committee, the Director General (DG) Operations Committee, the National Interdepartmental Shellfish Committee (NISC) and three Regional Interdepartmental Shellfish Committees (RISCs); the Pacific RISC, Quebec RISC and Atlantic RISC, as illustrated in Figure 1. While Figure 1 shows the ADM level committee reporting to the CSSP Deputy Ministers, there is no formal Deputy Minister level committee, however, the Deputy Ministers meet on an ad hoc basis, as needed.


The interdepartmental oversight committee structure is the mechanism in place to ensure each partner department delivers on its respective CSSP responsibilities as outlined within the Interdepartmental MOU. Leadership of the CSSP rests with CFIA, which is responsible for chairing the Assistant Deputy Minister (ADM) Steering Committee and the Director General (DG) Operations Committee. The ADM Steering Committee and DG Operations Committee represent the governance mechanism to provide program-wide oversight and strategic direction to the program’s delivery partners. The ADM Steering Committee is comprised of ADMs/VPs from all three partnering departments, as well as, Health Canada and Agriculture and Agri-Food Canada, when necessary. The DG Operations Committee is comprised of DGs/Executive Directors from all three partnering departments and Health Canada, as needed. The National Interdepartmental Shellfish Committee (NISC) makes national operational decisions and brings policy proposals and recommendations to the attention of the CSSP DG Operations Committee.

 

The NISC is responsible for coordinating implementation of the CSSP MOU which includes advising senior management on the effectiveness and progress of the CSSP. The committee must also prepare and table an annual report on CSSP performance at the CSSP ADM Steering Committee. The Regional Interdepartmental Shellfish Committees (RISC) co-ordinate program delivery in the regions and provide recommendations to NISC on all regional issues that require national direction or decision. The NISC is comprised of program staff from all partner departments while the RISCs are comprised of members from all three partner departments, relevant provincial authorities and industry. All levels of the interdepartmental governance committee structure include participation from DFO CSSP representatives.

As per the NISC Terms of Reference (TOR), each department/agency must select at least one NISC member through their own internal process and also places a limit on the number of representatives allowed for each department/agency. While the level or representation is not specified in the NISC TOR, departmental representation tends to be at the manager level. The audit found that there is inconsistent regional representation, with a mix of aquaculture, resource management, fishery officers, or Regulations Unit staff attending, depending on the region. While fishery officers are the face of the program in the region and are responsible for implementing the decisions made at the interdepartmental committees, only one region had fishery officer representation.

Within DFO, the Aquaculture Management Directorate, within the Ecosystems and Fisheries Management Sector, is the DFO lead for the CSSP, while C&P is responsible for compliance and enforcement activities. The Director General (DG) of the Aquaculture Management Directorate is responsible for DFO CSSP delivery nationally and the regional directors general are responsible for regional CSSP operations. The Departmental lead for CSSP moved from the Resource Management Directorate to the Aquaculture Management Directorate in 2013, due in part to the increased demands from the aquaculture sector for the development of additional shellfish harvesting areas under CSSP. However, only four out of five DFO CSSP regions have transferred CSSP activities from Resource Management to Aquaculture Management. This results in challenges in the Aquaculture Management Directorate’s ability to exercise its functional authority effectively in all regions.

At the departmental level, there is no internal DFO CSSP governance committee structure. Even though the regional directors general are responsible for regional CSSP operations, there is currently no mechanism to engage them in the interdepartmental governance structure. As such, regional differences are not being identified and considered in a timely manner to support decision making. This results in missed opportunities to share regional perspectives and best practices to develop nationally consistent program delivery. Therefore, there is a need to develop a process to facilitate communication and sharing of DFO CSSP information across the Department prior to and after the interdepartmental committee meetings to ensure sufficient regional input regarding proposed operational decisions.

Recommendation 1: It is recommended that the Senior Assistant Deputy Minister, Ecosystems and Fisheries Management create a DFO CSSP committee, chaired by the Director General of Aquaculture Management, with representation from both Conservation & Protection and Fisheries and Aquaculture Management, to discuss DFO CSSP issues and inform interdepartmental CSSP committee meetings, and to ensure regional implementation of decisions made at these meetings.

Management Response:

  1. 1.1 Establishment of a formal mechanism for the DG of Aquaculture to inform regional senior management of CSSP issues.
  2. 1.2 Schedule teleconferences with regional senior management in advance of CSSP meetings.

Target Completion Date: November 2017

Control Environment
The control environment is the set of standards, processes, and structures that provide the basis for carrying out internal control across the organization.Footnote 3 An effective system of internal control provides reasonable assurance of achievement of an entity’s objectives. In determining whether a system of internal control is effective, management exercises judgment in assessing whether each of the components and relevant principles is present and functioning and components are operating together. Policies, procedures, and tools support effective program design and delivery when they are established, maintained and communicated effectively.


We expected to find CSSP national policies, standardized operating procedures, guidance and reporting tools within an overall program framework to support effective and consistent program delivery and to ensure that DFO is able to demonstrate fulfillment of its responsibilities under the interdepartmental CSSP MOU.

DFO CSSP lacks a national program framework to ensure consistent program delivery across all DFO CSSP regions

While a CSSP MOU and Manual of Operations exist, DFO CSSP lacks a national program framework, with standard operating procedures that are implemented nationally. The authorities under which DFO participates in the CSSP flow from the Fisheries Act and the Management of Contaminated Fisheries Regulations. The program responsibilities for each partner department are outlined in the interdepartmental MOU and operating procedures are described in the Manual of Operations. A detailed examination of each of DFO’s responsibilities identified within the MOU, including the related DFO operating procedures from the CSSP Manual of Operations, was conducted to provide assurance that the department is fulfilling its obligations as per the MOU. The audit also selected a sample of prohibition orders and conditional management plans from fiscal year 2015-16 for further examination. While our assessment found that DFO is fulfilling its responsibilities under the MOU, the audit also found opportunities for improvement. Our findings by MOU responsibility are summarized below:

  1. opening and closing shellfish areas on the basis of :
    1. classification recommendations from ECCC, based on the sanitary and bacteriological water quality of the shellfish areas, and agreed to by the regional Shellfish Area Classification Committees; and
    2. recommendations from CFIA on marine biotoxin levels, and microbiological and chemical levels in shellfish areas;
  2. Analysis of Regional CSSP Patrol Policies revealed that all DFO CSSP regions have a documented process for the opening and closing of areas. A review of the DFO shellfish harvesting closure websites for each regionFootnote 4 demonstrates that the opening and closing of areas based on sanitary and bacteriological water quality (ECCC results) and for Biotoxin levels (CFIA results) for all DFO CSSP regions are made public. Our file review of a sample of prohibition orders revealed evidence of opening and closing shellfish areas on the basis of recommendations from ECCC and CFIA.

  3. posting, patrolling and enforcing shellfish closures in accordance with the Fisheries Act;

  4. Shellfish harvesting closures and shellfish safety information are available to harvesters and the general public on the DFO website.Footnote 5 Based on a site visit to one region, the audit team accompanied fishery officers on patrols to observe posting, patrolling and enforcement activities. The team patrolled shellfish harvesting areas and visually confirmed the existence of signs posted in the area. Additionally, while evidence gained through interviews and document review revealed that the posting of signs, patrolling and enforcement activities for CSSP are also being conducted in all other regions, the lack of standardized signage was identified as a challenge for shellfish harvesters who harvest across regions, since the signs vary from one region to the next. This is particularly true on the Atlantic coast, where regions are in close proximity to one another. Also, the signs that are posted may not clearly describe the boundaries of the shellfish harvesting areas. Finally, unclassified shellfish harvesting areas in one DFO CSSP region are considered to be in closed status, which means that signs are posted and the area is patrolled, while in other regions unclassified areas are excluded from program delivery and there are no posting, patrolling or enforcement activities.


  5. controlling shellfish relaying operations and harvesting for depuration operations;

  6. Bivalve molluscan shellfish harvested from a contaminated area must be subjected to depuration to eliminate microbiological risks after harvest, as outlined in the Manual of Operations. Shellfish harvested from a restricted or conditionally restricted area require a licence issued under the Management of Contaminated Fisheries Regulations (MCFR) and are subject to a depuration or relay protocol prior to marketing. Relay is the transportation of contaminated shellfish from a restricted or conditionally restricted harvest area to a clean water storage area or to a depuration facility. As such, the MCFR allows for a license to fish for food purposes in an area that is contaminated, following approval of a decontamination plan.

    Under the authority of the MCFR, DFO issues harvest licences, patrols shellfish areas, and controls harvesting of shellfish from classified areas. During our audit site visits, fishery officers were observed controlling shellfish relaying operations and harvesting for depuration operations. Further, CSSP Performance Reports for the past 3 fiscal years confirm that DFO has been issuing MCFR licences. In fact, the report for 2015/16 illustrates that the number of MCFR licences issued increased from 143 in 2014/15 to 248 in 2015/16, with the Gulf region having reported the largest increase of 45%, due to greater interest in the fishery for that region. The reported percentage of MCFR licenses issued versus requested was close to 100% for all regions, with the exception of the Newfoundland and Labrador Region, which no longer issues MCFR licences, due to an identified food safety risk for scallops in that region.

  7. implementing DFO elements of jointly developed Management Plans for "Conditionally Approved" areas;

  8. A Conditional Management Plan (CMP) is an agreement signed by relevant parties for the management of shellfish harvesting in conditionally classified areas. Conditionally classified areas include Conditionally Restricted and Conditionally Approved Areas, both of which need a CMP in place to allow for harvesting of shellfish in these areas. An area can be classified as conditionally approved or conditionally restricted based on the existence of a wastewater treatment or collection system, rainfall and/or seasonal conditions. The area will remain in a closed status until an appropriate CMP is developed. As per the DFO CSSP performance indicators for 2014/15, there were 25 CMPs across Canada and the audit team reviewed a sample from each DFO CSSP region. Our review revealed that all regions are using the CMP templates provided within the Manual of Operations and that management of CMPs is developed taking into consideration the complexities and unique attributes associated with each area. Our file review of a sample of CMPs and related incidents showed that CMPs are generally well documented and that the required annual reports are sufficiently complete. DFO treats the notification in the same manner as a formal recommendation for closure and issues a prohibition order and notifies external stakeholders to cease harvesting in the area immediately.

  9. providing notification to CFIA, ECCC, stakeholders and other interested parties, on locations, boundaries and timing of harvesting closures and openings;

  10. The audit revealed issues with the communication of shellfish harvesting area closures to industry and other stakeholders. This was noted as an issue affecting fishery officers’ ability to enforce violations, as they cannot provide sufficient evidence that the CSSP requirements were clearly communicated. At the time of the audit, the program did not have the ability to consistently and clearly communicate classification boundaries and closures in all regions. Therefore, industry groups, such as aquaculture, commercial, recreational and FSC harvesters were unable to access a clear depiction of the boundaries of shellfish harvesting areas. The primary means of determining which areas were open or closed for harvesting was to interpret the prohibition orders or fisheries notices on the DFO website. In order to address this program limitation, the Department, in collaboration with its CSSP partners, initiated a project to define CSSP mapping requirements and develop an online interactive mapping tool in 2013.

    Our file review of a sample of prohibition orders also revealed evidence of the tools and channels used to communicate shellfish harvesting information to external stakeholders, such as notifications via the Atlantic Catch Data service or the Fishery Notification Center in the Pacific. Although some improvements to the communication of shellfish harvesting area closures and the use of Quick Response (QR) codes to communicate closure status have been made in recent years, there remains room for improvement in the communication tools and channels used to inform shellfish harvesters of CSSP closures and classification of areas. However, the CSSP mapping tool was implemented in March 2017 and is expected to improve communication to shellfish harvesters and the general public.

  11. maintaining records of the opening and closing of shellfish areas, as well as records of enforcement patrols, in support of reviews by external or internal auditors, and providing CFIA and ECCC with annual patrol enforcement activity reports;

  12. In order to ensure effective control, the minimum frequency of patrol of a shellfish harvesting site is assessed based on shellfish productivity, ease of harvest, and difficulty of patrol. As per Regional CSSP Patrol Policies, sites are classified as low, medium, or high risk, as follows:

    Figure 2: Minimum patrol frequency based on risk category
    Risk CategoryMinimum Frequency of Patrol
    LowFour (4) times per 30 harvestable days.
    MediumEight (8) times per 30 harvestable days.
    HighSixteen (16) times per 30 harvestable days.

    Source: Regional CSSP Patrol Policies

    We did find evidence of the tracking of the opening and closure of shellfish areas, as well as records of enforcement patrols, both regionally and nationally. However, the audit revealed that data in the Fishery Enforcement Activity Tracking System (FEATS), which is used to report on these enforcement activities, may not be accurate due to regional inconsistencies in data entry. The United States Food and Drug Administration (US FDA) noted similar limitations in their CSSP audits in 2009 and 2013. The 2013 US FDA audit included a recommendation to continue the approval process to have FEATS reconfigured to include a field that will allow documentation of the actual number of patrols in any given shellfish growing area. Our file review of a sample of prohibition orders revealed that DFO CSSP regions were unable to demonstrate that sufficient patrols were completed. This has an impact on the ability of the program to accurately report to CSSP partners on the level of enforcement of shellfish harvest areas.

  13. consulting with CFIA and ECCC prior to the commencement of any new developmental or exploratory shellfish fisheries, and/or the issuance of any new licenses or permits thereto;

  14. Testing of this activity was not undertaken as CSSP is currently not entertaining the development of any new shellfish harvesting areas due to a lack of CSSP capacity, as decided at the June 2015 NISC meeting.

  15. participating in the CSSP audit program, as well as in external audits by such bodies as Health Canada and the U.S. Food and Drug Administration.

  16. The Department is actively participating in the CSSP audit program, which consists primarily of US FDA audits, completed every 3 years. The last completed US FDA audit report was issued in 2013, while the most recent US FDA audit was underway at the time of this audit, in 2016. The 2013 US FDA audit report included clearly defining the roles and responsibilities of DFO and CFIA, with regard to vessel overboard discharge and the development of harvester educational materials, as well as continued improvements to FEATS, to allow for documentation of the actual number of patrols in a given shellfish growing area.

    Based on a regional site visit, interviews, and a review of pertinent documentation, our analysis of the Department’s CSSP responsibilities as per the Interdepartmental MOU and the CSSP Manual of Operations, revealed that the CSSP Manual of Operations is adequately aligned with the CSSP Interdepartmental MOU, and that the procedures and guidance provided are sufficient to allow DFO to fulfill its CSSP responsibilities. However, the MOU and Manual of Operations are not sufficient to ensure consistent national program delivery. The lack of standardized CSSP processes, procedures and tools has resulted in inconsistent regional program delivery, such as varying signage and differing patrol practices for unclassified shellfish harvesting areas across DFO CSSP regions. Improved consistency and efficiency could be gained by standardizing DFO CSSP practices nationally.

Recommendation 2: It is recommended that the Senior Assistant Deputy Minister, Ecosystems and Fisheries Management, in collaboration with all DFO CSSP regions, develop a DFO CSSP program framework, which elaborates on the DFO responsibilities within the interdepartmental MOU and the procedures in the Manual of Operations, to guide program operations and improve national consistency.

Management Response:

  1. 2.1 Prepare a summary of CSSP roles, responsibilities and accountabilities (R,R&A) and how they are currently defined and assigned across CSSP regions.
  2. 2.2 Identify and implement changes required vis-à-vis how R,R&A’s are assigned across CSSP regions to establish a standardized and consistent approach to program delivery.
  3. 2.3 Update R,R&A documents and maintain in a central document repository on the CSSP Sharepoint portal.

Target Completion Date: December 2017

6.2 INFORMATION FOR DECISION MAKING (MODERATE RISK)

Information is necessary for the entity to carry out internal control responsibilities to support the achievement of its objectives. Management obtains or generates and uses relevant and quality information from both internal and external sources to support the functioning of internal control.Footnote 6


We expected processes would be in place to provide accurate, reliable and consistent information to support DFO CSSP decision making to ensure DFO is able to fulfill its responsibilities under the interdepartmental CSSP MOU.

DFO lacks reliable, accurate and consistent CSSP information for decision making

The CSSP obtains program information from a variety of sources. There is enforcement activity information that is obtained from systems such as the Fishery Enforcement Activity Tracking System (FEATS) and the Departmental Violation System (DVS) and there is harvesting data obtained from commercial harvesters.

In terms of enforcement data, as stated earlier, the audit found that there are data quality issues with FEATS, due to limitations in the functionality and connectivity of the system. This is important because DFO must be able to report on the level of enforcement activity as part of its commitment under the MOU.

The audit also revealed that there is a lack of data on shellfish harvesting levels and product value, due in part to limited reporting requirements and regional variation. Data for commercial harvest (wild commercial and aquaculture fisheries) and non-commercial harvest (recreational and food, social and ceremonial (FSC) fisheries) and the type of shellfish harvested is incomplete. For example, the reporting requirements for aquaculture vary from one DFO CSSP region to the next. Aquaculture shellfish harvesters must send data on the number of shellfish that have been harvested in a year as a condition of their license in some DFO CSSP regions, but not in others. As such, DFO lacks the ability to accurately track and report on shellfish harvesting statistics to inform decision making.

For example, as part of Pillar 2 of the CSSP Long-Term Sustainability Work Plan, CSSP partners reviewed the available harvest activity data, with a goal to support CSSP area classification review in order to re-align resources to where they are most needed. Based on estimated activity levels of commercial shellfish harvesting (wild commercial and aquaculture fisheries), 1,369 CSSP areas from across the country were ranked as low, medium or high priority for regional CSSP delivery. Areas having significant and sustained commercial harvesting have the highest priority for program delivery and are considered classified, and must be routinely monitored for sanitary and biotoxin conditions, to minimize the health risks associated with the consumption of bivalve shellfish. Those areas that were deemed as high or medium priority (621) will have program delivery maintained at current levels. For CSSP areas that were identified as low priority (748), the intent is to inform shellfish harvesters that these areas will be declassifiedFootnote 7 and CSSP delivery will cease if no new harvest data is brought forward to justify program delivery.

The work undertaken by the CSSP partners during the classification review was important to inform decisions on program delivery, however, the review was based on shellfish harvesting data that was available at the time, which was incomplete. Having reliable and complete data is important to ensure that areas are properly classified, resources are allocated based on the level of activity and enforcement activities can be aligned with area classifications.


Recommendation 3: It is recommended that the Senior Assistant Deputy Minister, Ecosystems and Fisheries Management and the regional directors general of all DFO CSSP regions, develop processes to obtain accurate, reliable and consistent shellfish harvesting data to support DFO CSSP decision making.

Management Response:

  1. 3.1 Prepare a Table of Contents for a set of standardized processes to collect harvesting data.
  2. 3.2 Gather the available documents describing existing regional processes to collect harvesting data.
  3. 3.3 Develop national process for harvest data collection.
  4. 3.4 Develop a specific plan for a national DFO CSSP harvest data repository accessible to all CSSP staff and regions, in collaboration with the Chief Information Officer.

Target Completion Date: March 2018

6.3 FINANCIAL AND HUMAN RESOURCES MANAGEMENT (MODERATE RISK)

An integrated departmental control framework that includes assets, money, people, and services should be established at all levels within the organization and should define how activities should be performed while ensuring its underlying principles are clear to employees.

Financial Management
We expected that CSSP expenditures are monitored, tracked and reported to support sound and informed decision-making.

The accuracy and reliability of DFO CSSP financial reporting could be improved

The audit found that, while some monitoring of CSSP resources is taking place, the Department lacks adequate information on its financial and human resource allocations to ensure sound program management. There is a significant gap in the information available on expenditures and it is difficult to accurately describe the level of activities and the associated resources due to incomplete budgeting and financial tracking for CSSP related activities. A national CSSP project code was created and communicated to the regions in 2013 to improve financial tracking of CSSP expenditures; however, not all regions use this project code on a consistent basis. Also, for those that were tracking expenditures against budget, they did not consistently include the full cost of all CSSP related expenditures.

Reporting of historical CSSP expenditures for fiscal years 2013-2014 to 2015-2016 show that approximately 70% of DFO CSSP expenditures were incurred in one DFO CSSP region, even though less than half of all DFO CSSP activities take place in that region. Also, Fishery Enforcement Activity Tracking System (FEATS) reporting showed that for the last three years, C&P CSSP patrol hours were over 25,000 hours per year on average, but in 2015-2016 only $440,000 of expenditures were recorded by C&P across all regions and one region did not record any expenditures at all. Based on the average C&P CSSP patrol hours and the average hourly salary for a fishery officer, the annual CSSP expenditures for C&P should be closer to $1M.

Recommendation 4: It is recommended that the Senior Assistant Deputy Minister, Ecosystems and Fisheries Management and the regional directors general of all DFO CSSP regions, ensure that CSSP expenditures are tracked and reported in a reliable and consistent manner to support decision-making and that the financial resource allocations made to CSSP are appropriate to meet program requirements.

Management Response:

  1. 4.1 Each CSSP Region and the NCR to take steps to ensure accurate reporting of DFO resources allocated to deliver the CSSP from 2017-18 onward.
  2. 4.2 Undertake an analysis, including a risk assessment, of DFO resources allocated to deliver the CSSP. Use the results in preparation of the CSSP HR Plan (see action to address recommendation 5).

Target Completion Date: March 2018

Human Resources Management
Effective management of human resources is essential to the sustainability and efficiency of a department and the quality of its services. The development and implementation of an adequate human resources (HR) plan which addresses immediate, short-term and future resource requirements not only supports a responsible succession plan and the management of knowledge transfer, but also demonstrates a commitment to the development and maintenance of employee competencies.

We expected to find a departmental CSSP human resources plan to attract, develop and retain individuals with the appropriate capacity and skills, in order to deliver the program effectively.

An analysis of CSSP HR requirements should be undertaken to identify key positions, current and anticipated needs, and any required training and development

Successful delivery of DFO CSSP responsibilities requires sufficient capacity and availability of CSSP staff. Attracting and retaining a competent and representative workforce with the appropriate skills to meet the Department’s current and future needs is fundamental to the sustainability of the DFO CSSP. As such, DFO CSSP management is currently working on a Long-Term Sustainability Work Plan to address CSSP resource constraints and continued economic growth pressures. The program must continue to adapt to changing requirements and increasing industry demands, such as increasing aquaculture shellfish production.

The program has not identified current organizational capacity, including budgeted amounts for salary and operations and maintenance (O&M) or the number of CSSP full time equivalent (FTEs). The 2016-2017 DFO Corporate Risk Profile (CRP) specifies the Department’s aging workforce, with approximately one-third of the workforce eligible for retirement by 2019. Given the potential human health risks associated with the consumption of contaminated bivalve molluscan shellfish and the specialized knowledge required, it is important to plan for succession of all DFO CSSP employees, including knowledge transfer and training. New C&P fishery officers get some training on CSSP via the Fishery Officer Career Progression Program (FOCCP); however, no additional formal training is available for fishery officers or for new employees with CSSP responsibilities. As such, there is a need for career development, talent management and succession planning. Strategies aimed at recruitment, staffing, retention, development, succession planning, training and knowledge transfer can then be developed and implemented for key positions to ensure DFO CSSP responsibilities are met.

Recommendation 5: It is recommended that the Senior Assistant Deputy Minister, Ecosystems and Fisheries Management and the regional directors general of all DFO CSSP regions, identify the appropriate level of human resource allocations across all regions, and implement a strategy to attract, develop and retain qualified individuals for key DFO CSSP positions.

Management Response:

  1. 5.1 Develop and implement a DFO CSSP HR Plan that:
    1. Defines key CSSP positions;
    2. Assesses CSSP HR requirements;
    3. Plans for succession;
    4. Documents training needs by position.

Target Completion Date: March 2018

7.0 AUDIT OPINION

Based on the audit findings, our opinion is that improvements to the current governance, risk management and control processes in place are needed to ensure they are adequate and working effectively, in order for DFO to meet its CSSP program delivery requirements. Specifically, the audit found that there is a need to strengthen DFO CSSP governance committee structure, reporting structure and national consistency, as well as, improve the reliability, accuracy and consistency of CSSP information. Opportunities exist to enhance existing practices and to strengthen the adequacy and effectiveness of internal controls, particularly in the areas of standard operating procedures and financial and human resource management.

8.0 STATEMENT OF CONFORMANCE

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The extent of the examination was planned to provide a reasonable level of assurance with respect to the audit criteria. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed on with Management. The opinion is applicable only to the entity examined and within the scope described herein. The evidence was gathered in compliance with the Treasury Board Policy and Directive on Internal Audit. The audit conforms with the Internal Auditing Standards for the Government of Canada, as supported by the results of the Quality Assurance and Improvement Program. The procedures used meet the professional standards of the Institute of Internal Auditors. The evidence gathered was sufficient to provide Senior Management with proof of the opinion derived from the internal audit.

APPENDIX A: LINES OF ENQUIRY AND AUDIT CRITERIA

The audit criteria are presented in the table below, by audit line of enquiry.

Audit Criteria
Audit Criteria
Line of Enquiry 1 – Governance and control environment
Criterion 1.1: Departmental governance and oversight has been established, is operating effectively and ensures DFO CSSP is fulfilling its responsibilities as per the Memorandum of Understanding (MOU).
Criterion 1.2: Roles, responsibilities and accountabilities are clearly defined, documented and communicated.
Criterion 1.3: Documented Departmental operating procedures for CSSP have been developed, are current and communicated.
Line of Enquiry 2 – Financial and human resources management
Criterion 2.1: A Departmental human resources plan exists to attract individuals with the appropriate capacity and skills, develop and retain qualified individuals and is reviewed and updated regularly.
Criterion 2.2: Adequate financial and human resources have been allocated to CSSP, in order to fulfill Departmental responsibilities under the CSSP interdepartmental MOU.
Criterion 2.3: Monitoring and reporting of CSSP expenditures is being performed to inform decision making.
Line of Enquiry 3 – Risk Management
Criterion 3.1: A documented approach to identifying, assessing and managing departmental CSSP risks has been developed, implemented and updated regularly, including senior management assessment and mitigation/response.
Line of Enquiry 4 – Communication and information management
Criterion 4.1: Processes are in place to communicate relevant and timely information to internal and external stakeholders and channels exist to obtain feedback.
Criterion 4.2: Information systems in place provide accurate, reliable and consistent information to support CSSP management decision making.

APPENDIX B: LIST OF ACRONYMS

ADM:
Assistant Deputy Minister
C&P:
Conservation and Protection
CFIA:
Canadian Food Inspection Agency
CMP:
Conditional Management Plan
CSSP:
Canadian Shellfish Sanitation Program
DFO:
Fisheries and Oceans Canada
DG:
Director General
ECCC:
Environment and Climate Change Canada
FEATS:
Fishery Enforcement Activity Tracking System
FSC:
Food, social and ceremonial
HR:
Human Resources
MCFR:
Management of Contaminated Fisheries Regulations
MOU:
Memorandum of Understanding
NHQ:
National Headquarters
NISC:
National Interdepartmental Shellfish Committee
RISC:
Regional Interdepartmental Shellfish Committee
TOR:
Terms of Reference
US FDA:
United States Food and Drug Administration