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Analysis Report Regarding the Denton Fire Department Uniform Program Internal Audit Department 215 E. McKinney St., Denton, TX 76201  (940) 349-7228 OUR CORE VALUES Integrity  Fiscal Responsibility  Transparency  Outstanding Customer Service DATE: December 16, 2020 TO: Kenneth Hedges, Fire Chief FROM: Madison Rorschach, City Auditor CC: Honorable Mayor and Members of the City Council Todd Hileman, City Manager Tiffany Thomson, Human Resources Director Analysis Report Regarding the Denton Fire Department Uniform Program Purpose: On November 24, 2020 the City Auditor met with Fire Department management to discuss potential issues with the Fire Department’s Uniform Program. In particular, the Fire Department was concerned about new requirements created by an update to the National Fire Protection Association’s Standard 1851 “Standard on Selection, Care, and Maintenance of Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting.” The Department believed it would be helpful for Internal Audit to review the Uniform Program to identify any potential issues. In response, the Internal Audit Department entered into an Analysis Services Agreement with the Fire Department in order to provide information on the following questions: 1) How does the Fire Department’s uniform program comply with NFPA Standard 1851? 2) Were fire uniforms stored and disbursed according to Department policy during fiscal year 2019-20? 3) Was the current fire stationwear uniform contract solicited in accordance with applicable regulations? 4) Were the current firefighting personal protective equipment contracts solicited in accordance with applicable regulations? Methodology: 1. Executed Non-Audit Services Agreement with the Denton Fire Department. 2. Reviewed the 2020 National Fire Protection Association’s (NFPA) Standard 1851 and identified required parts of a uniform program. 3. Compared the Denton Fire Department’s Uniform Program including policies and procedures to the 2020 NFPA Standard 1851’s requirements. 4. Verified that critical aspects of the Uniform Program were operating effectively based on document review and interviews. 5. Discussed PPE and stationwear storage and disbursal practices with Denton Fire Department management. 6. Estimated costs of changing the PPE distribution model. 7. Examined solicitation documents for purchase of PPE and stationwear to ensure compliance with applicable regulations. Page2 Summary of Review: Compliance with NFPA Standard 1851 Based on a review of the 2020 National Fire Protection Association’s (NFPA) Standard 1851, there are generally eight required parts of a personal protective ensemble (PPE) uniform program.1 These are outlined in Table 1 along with a summary of the results of this assessment: Table 1: Summary of NFPA Standard 1851 Requirements Program Part Critical Requirements Assessment Result2 Records • Records including specific information for each protective ensemble. Needs Improvement Protecting the Public • SOP minimizing public exposure to contaminated personal protective ensembles. Adequate Selection • Periodic risk assessment performance; • Systemization of ensemble evaluation as part of procurement; and • Point of delivery inspections. Adequate Inspection • Minimum equipment required to conduct inspections; • Guidelines for determining if an element is soiled; • Routine inspections upon issue, at the beginning of duty, and after each use; and • Advanced and linear inspections conducted annually and if there is potential damage. Needs Improvement Cleaning • Cleaning after each use in accordance with standards; • SOP for preliminary exposure reduction; and • Advanced cleaning required twice in 12-month period. Needs Improvement Repair • Repairs in accordance with standards. Adequate Storage • Ensemble storage environment requirements. Adequate Retirement, Disposition & Special Incident Procedures • Develop specific criteria for removal including disposal within 10 years of manufacture; and • Special incident procedure developed. Adequate Records. Based on discussion with Denton Fire Department (DFD) staff, there is a complete inventory record of active PPE elements. This record generally includes, who the element is issued to, manufacturer information, date of purchase, and lifespan. This record generally does not include the dates for when elements were retired and disposed. While the standard requires these dates be documented, it does not specify a retention period. A separate inventory record is maintained for inactive PPE inventory. 1 The personal protective ensemble is generally made up of six elements including: a coat, pants, boots, a helmet, three pairs of gloves, and two particulate hoods. 2 Details of adequate assessment results can be viewed in Appendix A. Page3 Inspection. According to DFD staff, inspection gloves are available to all firefighters as needed; however, the requirement to wear these gloves during inspection is not clearly formalized in the Department’s PPE policy. The policy does include guidelines for what a firefighter should check for when conducting routine inspections and requires routine inspections to be performed per NFPA Standard 1851. Documenting routine inspections is not required per NFPA Standard 1851. Still, there is currently no procedure to ensure that routine inspections are being performed by staff as required. Based on discussion with DFD staff, they have a software that could be used to require each firefighter to complete a routine inspection checklist each day they are on duty. The City of Denton has contracted with a verified independent service provider to perform inspections on bunker gear annually. According to DFD staff, these inspections are generally completed when a firefighter is not on shift. The contractor provides a record of completed inspections and their results to DFD; however, without a complete inventory record it is not possible to verify if all required inspections were performed. Cleaning. The City of Denton has contracted with a verified independent service provider to perform advanced cleanings on bunker gear semiannually. According to DFD staff, these cleanings are generally completed when a firefighter is not on shift. The contractor provides a record of completed cleanings to DFD; however, without a complete inventory record it is not possible to verify if all required cleanings were performed. According to DFD staff, firefighters can also perform advance cleanings on their PPE at each station with specialized cleaning equipment and are empowered to determine how their PPE should be cleaned after each use. That being said, there does not appear to be a process to document these cleanings. Instead, only advance cleanings performed by a third-party vendor are documented. Without this documentation, it is not possible to verify that cleanings were performed in accordance with standards. Finally, DFD’s PPE policy includes a requirement for PPE to undergo preliminary exposure reduction after each use and outlines a procedure. This procedure includes all minimum requirements per the NFPA Standard 1851, including: • A description of dry mitigation techniques; and • A description of wet mitigation techniques. Uniform Distribution Fire Department staff generally have two types of uniforms including: 1. The personal protective ensemble (PPE), which is heavily regulated as discussed previously to minimize contamination to firefighters and the public; and 2. Stationwear, which is worn by on duty firefighters at all other times. The following section details how each type of uniform is disbursed to firefighters. Page4 Personal Protective Ensemble. The Denton Fire Department (DFD) generally purchases a firefighter a set of PPE every five years. This practice allows DFD to ensure that most firefighters have two sets of the PPE while spreading acquisition costs out over time. Based on information received from DFD, this practice has resulted in 38 firefighters not having a second set of gear currently., Table 2 breaks this down by Station. Table 2: Firefighters without Two PPE Sets by Station (2021) Station Total Assigned Firefighters Percentage without Two PPE Sets Station 1 37 22% Station 2 18 39% Station 3 22 23% Station 4 19 21% Station 5 20 25% Station 6 20 30% Station 7 18 6% Station 8 14 14% All: 168 23% Under NFPA standards, firefighters are generally required to perform an advance cleaning of their gear if they respond to a structure fire as soon as possible. Over the past two calendar years, there have been a total of 82 combustion incidents, which may have required the responding firefighters to perform advanced cleaning on their gear. Once an advance cleaning is performed the PPE must airdry, so the firefighter should have a second set to wear for the rest of their shift. Out of the 731 days during calendar years 2019 and 2020, there were five days where two combustion incidents occurred. In total, four firefighters3 responded to two combustion incidents on one of those days meaning they would have needed three sets of PPE for that shift. These incidents are detailed in Table 3: Table 3: Days with Two Combustion Incidents (2019-2020) Incidents Date No. Firefighters Responding to Both Incidents Date No. Firefighters Responding to Both 05/01/19 0 09/05/20 0 08/07/19 1 10/14/20 3 06/08/20 0 Total: 4 Based on history, DFD would need to purchase every firefighter three sets of PPE gear to be prepared for the worst-case scenario. On the other hand, on average one combustion incident occurs on about 10 percent of days throughout a year and more than one combustion incident occurs on less than one percent of days. Table 4 3 All four of these firefighters appear to have two sets of gear. Page5 estimates the costs of changing the PPE distribution model to address these risks; detailed calculations can be seen in Appendix B. Table 4: PPE Distribution Model Options4 Distribution Model Active Inventory “Catchup” Cost Min. Additional Maint. Costs Per Year Current Model 298 PPE Sets $0 $0 All – Three Sets 504 PPE Sets $672,378 $18,128 All – Two Sets 336 PPE Sets $124,030 $3,344 It should be noted that DFD also has an inventory of “inactive” PPE sets, which can be loaned out to firefighters when their sets are not available for use.5 In order to obtain a loaner set of PPE, the firefighter must go to Fire Station 4 and identify a set of PPE that will safely fit them. It may be possible to use this inventory of inactive gear to ensure that all firefighters have at least two sets of PPE available to them for use without significantly changing the current distribution model. When considering this option, DFD should consider the following factors: • How many sets of PPE each firefighter has currently; • The size of each firefighter and the amount of inactive inventory that could safely fit them; • The availability of safely sized, inactive PPE for each shift; and • The time and resources it would take to obtain an inactive set of PPE during a shift. Stationwear. DFD also purchases new stationwear for its members annually. For this process, each firefighter is assigned a budget of money and can pick new uniform items they want from a defined list. For the past few years this budget has been $400 for each firefighter. In addition, any new firefighters are given a standard set of stationwear when they join. Once all orders are received, stationwear is procured through a City contract and delivered to the Battalion Chief assigned additional quartermaster duties at Station 4. From there the order is split up and delivered to each firefighter, who is responsible for storing their stationwear appropriately. Procurement Review The Denton Fire Department (DFD) currently has two contracts for uniforms. The procurement process for each of these contracts is detailed below. In addition, DFD is currently in the process of contracting for the personal protective ensemble (PPE) 4 All estimated costs are in addition to the current PPE replacement budget. 5 This may be because the PPE is being cleaned or is out for repair. *All costs estimated in Table 4 would be in addition to DFD’s F20-21 PPE budget of $242,588. Page6 helmets, gloves, boots, and hood elements. According to DFD staff, the Department has not had contracts for these items previously. PPE Coat and Pants. The City issued a request for proposal for the coat and pant elements of its PPE on April 28, 2017 and received five responses to this solicitation. These responses were evaluated based on the following criteria: • 50% based on price; • 10% based on the number of days to delivery; • 10% based on probably performance under contract; and • 30% based on a wear test performed by a group of Denton firefighters. Three of the responses were evaluated by four firefighters and the remaining two were evaluated by two and three firefighters respectively. These evaluations were based on a standardized form, which were available for review. A five-year contract was awarded to CASCO for a total of $600,000 on June 17, 2017 via ordinance 2017-175. Stationwear. The City issued an invitation for bid via its electronic bidding system for DFD stationwear uniforms on August 25, 2019 and received five responses to this solicitation. It should be noted that three of these vendors did not completely fill out the pricing sheet. In order to accurately compare the prices of each vendor, Purchasing assumed the price for no bid items matched the highest bid price from vendors who completed the line item. Table 5 illustrates this process: Table 5: Stationwear Bid Comparison Vendor Bid Cost Lines Missing Contract Cost Est. by Purchasing Impact Promotional $203,040 0 $203,040 G T Distributors $155,936 10 $217,352 Ad Vision $160,683 6 $230,123 G and G Source $234,225 0 $234,225 Promo Solutions $30,694 20 $252,262 A three-year contract was awarded to Impact Promotional Services for a total of $350,000 on Nov. 5, 2019 via ordinance 19-2574. Conclusion: The following summarizes the answers to the questions posed at the beginning of this report: 1. Based on a comparison of DFD’s uniform program to NFPA Standard 1851, the biggest issue appears to be that records are not being adequately maintained. A complete record of PPE inventory is required to ensure that inspections and cleanings are being performed as required. Similarly, there is currently no system to document inspections and cleanings performed in-house. In combination, this means it is difficult to verify if required inspections and cleanings are occurring. Page7 2. There is currently no formal policy that guides DFD uniform disbursement. That being said, current uniform disbursement practices generally ensure that stationwear is distributed to firefighters equitably. As for personal protective ensembles (PPE), current practices ensure that most firefighters (about 77%) have adequate PPE available if one combustion incident occurs. Changes to this distribution model could decrease the risks associated with more than one combustion incident occurring in a day; however, these options come with higher acquisition and maintenance costs. Inactive PPE inventory could also be used to reduce these risks after considering several factors. 3. Based on a review of the solicitation documentation, the Denton Fire Department’s stationwear uniforms generally appear to have been procured in compliance with applicable procurement regulations. An appropriate solicitation method was used, and the contract was awarded to the lowest complete bid. 4. Based on a review of the solicitation documentation, DFD’s coat and pant elements for PPE generally appear to have been procured in compliance with applicable procurement regulations. An appropriate solicitation method was used, and the contract was awarded based on detailed evaluation results. Finally, contracting for other PPE elements going forward should provide further assurance that DFD is complying with procurement regulations. This report is intended to be informational only and as such, no recommendations have been made; however, Internal Audit is available for additional consultation as requested. Management Response: The Fire Department has reviewed the Analysis Report of the Uniform Program completed by the Internal Audit Department. The summary of review identifies three out of eight categories of NFPA Standard 1851 that is categorized as Needs Improvement. The DFD acknowledges this assessment as fair and has already initiated new processes that will create a more robust documentation system and a single repository for records related to PPE and Uniforms. In lieu of substantial budget request to fulfill the standard requirement of cleaning and inspection post combustion incident, inactive gear will be housed at one location and if needed distributed to the necessary personnel until a time every employee assigned to the Operations Division is issued two complete sets of PPE. An official policy on uniform disbursement is currently in the development stage with the expectation of completion in second quarter of FY 20/21. Page8 Appendices: Appendix A: Adequate Program Part Details Protecting the Public. The Denton Fire Department’s (DFD) revised Personal Protective Equipment policy includes all minimum requirements per the 2020 National Fire Protection Association’s (NFPA) Standard 1851, including: • Members shall minimize the public’s exposure to soiled or contaminated PPE and avoid wearing PPE to non-fire related emergencies; • Members shall not wear PPE inside station living quarters or other department facilities; • Soiled and contaminated PPE elements … shall not be take home, washed in the home, or washed in public laundries unless the business is dedicated handling firefighting protective clothing; and • Contaminated PPE shall not be transported in the apparatus crew compartment unless placed in protective case or bag. Selection. The most recent fire risk assessment was contracted in 2020 and is currently under way. In addition, for the most recent solicitation for firefighting bunker pants and coats, a standardized wear exercise was conducted and documented to ensure that evaluation was systemized. According to the Battalion Chief assigned quartermaster duties, personal protective ensemble (PPE) elements are inspected when received to ensure there are no issues. While these inspections are not documented, this issue is addressed in a separate section of this analysis. Repair. All PPE repairs are completed by the City’s PPE cleaning, inspection, and repair contractor. This contractor is a verified independent service provider as required by NFPA standards. Storage. As part of this project we did not observe the storage locations of PPE for every fire station. Fire Department staff stated that in the new fire stations there is a dedicated room to store PPE and in the older fire stations, PPE is stored all in one place as far from living quarters as possible. Retirement, Disposition, & Special Incident Procedures. DFD’s PPE policy includes a PPE retirement procedure. This procedure includes all minimum requirements per the NFPA Standard 1851, including: • Appropriate PPE useful life requirements; • Requirements to dispose of PPE that is 10 years old, that cannot be cleaned, or cannot be repaired; and • Disposal method requirement including exemption for training purposes. In addition, the PPE policy includes a special incident procedure. This procedure includes all minimum requirements per the NFPA Standard 1851, including: • Immediate removal from service; • Chain of custody and storage requirements; • Qualifications for individuals to examine the PPE; and • Retention period guidelines. Page9 Appendix B: Cost Estimate Calculations Table 6: Distribution Model Option Inventory Calculations Distribution Model Two Set Firefighters One Set Firefighters Inventory Total Inventory Additions Current Model 260 38 298 0 All – Three Sets 390 114 504 206 All – Two Sets 260 76 336 38 Table 7: “Catchup” Cost Calculations Element6 Cost All – Three Sets (Add 206 Sets) All – Two Sets (Add 38 Sets) Coat (1) $1,363.48 $280,876.88 $51,812.24 Pant (1) $1,210.10 $249,280.60 $45,983.80 Boots (1) $275.50 $56,753.00 $10,469.00 Gloves (3) $99.89 $20,577.34 $3,795.82 Helmet (1) $255.00 $52,530.00 $9,690.00 Hood (2) $60.00 $12,360.00 $2,280.00 PPE Set: $3,263.97 $672,377.82 $124,030.86 Table 8: Additional Minimum Maintenance Costs Element7 Cleanings Cost Inspection Cost All – Three Sets (Add 206 Sets) All – Two Sets (Add 38 Sets) Coat (1) & Pant (1) $19 $8 $9,476 $1,748 Boots (1) $5 $5 $3,090 $570 Gloves (3) $3 $3 $1,854 $342 Helmet (1) $5 $5 $3,090 $570 Hood (2) $1 $1 $1,236 $228 PPE Set: $33 $22 $18,746 $3,458 6 Coat and pant costs are based on prices increases from contract 6432. Other PPE element prices are based on quotes received from DFD staff. 7 All cleaning and inspection costs are based on prices from contract 6619.