Assurance Report: Audit of Public Services and Procurement Canada vaccination process—Phase 2

Vaccination attestation validation

To support the vaccination attestation validation process, the branch prepared several documents examined in Phase 1, such as:

• the “Procedure for Validating Attestations and Verifying Proof of COVID-19 Vaccination,” which outlined the processes and procedures for conducting validations of the attestations of vaccination status
• the “Human Resources Branch Attestation Verification Team Playbook,” which provided information regarding the roles and responsibilities of the Attestation Verification Team Coordination Manager, Attestation Verification Team Members/Verifiers and Labour Relations

The branch provided a Microsoft Excel list of the 1,007 employee names, which were tested by the Human Resources Branch team. The sample size of 1,007 was calculated using the “Guideline on sampling for verifications of attestations and consent forms” developed by the Office of the Chief Human Resources Officer to assist with the development of verification processes, and to ensure they meet auditing requirements. The list included information such as employee name, date of vaccination, meeting dates and verification of vaccination status.

In order to confirm that the process was adequately implemented and followed, we selected a random sample of 279 employees (28%) out of the 1,007 employees (details in Appendix C: Sampling strategy). During our testing, we verified that key steps identified such as the Human Resources Branch and employee verification meetings were conducted. We reviewed the meeting notes between the Human Resources Branch and the employee as no evidence of the employee’s vaccination information was retained. The meeting notes recorded the employee’s name, date of the meeting, vaccination date and whether it was the first or second vaccination dose. This information was then compiled into an attestation listing.

During our review, we compared the meeting information to the Government of Canada Vaccination Attestation Tracking System (GC-VATS). This ensured that the meeting vaccination information was consistent with the GC-VATS listing, which was used to track the employee’s vaccination status. It should be noted that, during the month of October 2021 when the vaccination attestations were being conducted, the GC-VATS listing was pulled weekly. But after the final attestation date of October 29, 2021, the reports were generated on an ad-hoc basis in order to follow up with employees.

During our testing, there were 5 instances where the employee meeting dates could not be confirmed via the Human Resources Branch calendar. We were informed that meetings were set up by email or Microsoft Teams, and our review of additional evidence confirmed that the meeting requirements were conducted by the Human Resources team as such the lack of a formal invitation was not deemed to be an exception.

We also found 8 instances of missing process information:

• for 4 employees, the vaccination attestation dates were not listed on the Excel attestation listing, and the employees’ names were not found on the GC-VATS listing
• for 3 employees, their vaccination attestation dates were not listed on the Excel attestation listing
• for 1 employee, their name could not be found on the GC-VATS listing

Regarding the 8 instances, although the information was not included within the Excel attestation list, we verified that the employees had all been fully vaccinated by the required deadline, reviewed their completed attestations, and reviewed evidence that validation meetings were conducted. These instances all related to the lack of documentation of key activities in the established vaccination attestation validation process but do not relate to employee non-compliance with vaccination requirements. We found that all employees in our sample were vaccinated by the required deadline.

However, the 8 exceptions out of our sample of 279 resulted in an error rate of 2.9%, which is below our 5% threshold. When we extrapolated the 2.9% error rate across the population of 1,007 employees, we expect 29 exceptions.

In addition, in our sample of 279 files, we did not find any cases where an employee made a false attestation. We were also informed by the Human Resources Branch that in their sample of 1,007 files, there were no false attestations made. We concluded that overall the branch’s operational processes and procedures for the vaccination attestations, as documented in Phase 1, were adequately implemented and followed.

Duty to accommodate

The branch developed key documents, which were examined in Phase 1 to support duty to accommodate situations such as the “PSPC Management Processes for the Implementation of the Policy on Vaccination,” which provided management processes and procedures for unvaccinated employees requesting accommodation, and the “Employee attestation indicates employee is unvaccinated and requesting accommodation: Process for managers,” which outlined the process for a manager to follow when receiving a request for accommodation. The types of accommodation requests included requests related to a medical contraindication (symptom or medical condition that is a reason for a person to not receive a particular treatment or procedure because it may be harmful), religious grounds and any other prohibited grounds of discrimination in the Canadian Human Rights Act.

The branch provided us an Excel list of 326 employees who requested a duty to accommodate from which we choose a sample of 177 (54%) to verify (details in Appendix C: Sampling strategy). The list included items such as employee name, accommodation request, management decision and the status at various dates. We tested the controls within the following stages of the Duty to Accommodate process: Request for accommodation, Labour Relations recommendation, Ad-hoc Advisory Group recommendation, Director General approval, and communication of decisions and next steps, as required, to the requestor.

During our testing, we found 1 instance where the Ad-hoc Advisory Committee did not provide a recommendation on the accommodation request, in accordance to the Duty to Accommodate processes and procedures. For this instance, the assessment was placed on hold as the requestor was on an extended sick leave and the return to work date was unknown. The employee was notified of the policy suspension and that the assessment would also be suspended. As the file was put on hold, we did not consider this an exception.

In our sample of 177, there were 103 samples where the employees were not granted accommodation, and in all cases the Human Resources Branch provided evidence to show that all required steps within the accommodation process were completed. Once the process concluded that no accommodation would be granted, the employee would be placed on administrative leave without pay or the employee could receive the vaccine in order to avoid being placed on administrative leave without pay.

As we verified a sample of employees in our vaccination attestation validation and administrative leave without pay testing, we did not conduct additional testing to verify if the employees who were not granted the accommodation, subsequently got vaccinated or were placed on administrative leave without pay. Our results of the vaccination attestation validation and administrative leave without pay testing are presented within this report under their respective headings.

Based on our analysis, we concluded that Human Resources Branch had evidence to support that they adequately followed and implemented the established operational processes and procedures in addressing employee requests for accommodation.

Administrative leave without pay

The “PSPC Management Processes for the Implementation of the Policy on Vaccination” examined in Phase 1, provided management processes and procedures for placing an employee on leave without pay. Employees who should have been put on leave without pay were clearly defined. The process detailed a list of actions, deadlines for the actions, and identified who was responsible to act. The branch provided an Excel list of 226 employees who were put on administrative leave without pay. From this population, we chose 143 (63%) employees to validate (details in Appendix C: Sampling strategy). The list included items such as employee name, the reason for being put on leave without pay and the effective start date of the leave. The branch also provided the My HRResource portal list that recorded the information of employees who were placed on administrative leave without pay, including their leave start dates.

In our analysis, we reviewed the emails along with the leave-without-pay letter that managers sent to unvaccinated employees which confirmed that the manager communicated the leave without pay status to the employee. The emails and leave without pay letters noted the unvaccinated status and the effective leave without pay start date. We also compared the leave without pay start dates stated on the letters to those on the My HRResource portal list to confirm that they were the same date. We also reviewed the My HRResource portal list to verify whether managers completed the leave without pay process in the system. The existence of the employee’s name on the portal list confirmed that the managers completed the processes.

We found 5 samples with exceptions to the completion of key activities in the administrative leave without pay process. However we did additional testing to confirm that the employees were adequately placed on administrative leave without pay. The following indicates the missing information for each of the 5 samples.

• sample A: did not have a leave without pay email sent from manager to the employee
• sample B and sample C: missing leave without pay letters and leave without pay emails sent from manager to the employee
• sample D: leave without pay start date on the leave without pay letter differed by 1 day from the date on the My HRResource portal list
• sample E: did not have a leave without pay email sent from the manager to the employee, and the leave without pay start date on the leave without pay letter differed by 1 day from the date on the My HRResource portal list

To confirm that the employee was appropriately placed on administrative leave without pay, we completed the following additional procedures.

• sample A: we verified that the information on the employee’s leave without pay letter was accurate, and checked the My HRResource portal list and confirmed that the employee was placed on leave consistent with the letter
• sample B and sample C: we reviewed screenshots from MYGCHR which showed the leave without pay start dates, thus confirming that the employees were placed on leave
  • we compared the leave without pay start dates to those on the My HRResource portal list, and confirmed that the dates were the same
• sample D: we could not find additional support to explain the 1 day difference in start dates
• sample E: we verified that the information on the employee’s leave without pay letter was accurate and checked the My HRResource portal list and confirmed that the employee was placed on leave consistent with the letter
  • however, we could not find additional support to explain the 1-day difference in start dates

The exceptions noted all related to the lack of documentation of key activities in the established Administrative Leave Without Pay process. However we found that all employees in our sample were appropriately placed on administrative leave without pay.

The 5 exceptions out of our sample of 143 resulted in an error rate of 3.5%, which is below our threshold of 5%. When we extrapolated the 3.5% error rate across the population of 226 employees, we expect 8 exceptions.

Based on the work conducted, we concluded that overall the Human Resources Branch had the evidence to confirm and validate that the process for putting an employee on administrative leave without pay was adequately implemented and followed by managers.

Return to work from leave

The “PSPC Management Processes for the Implementation of the Policy on Vaccination,” examined in Phase 1, provided management processes and procedures for employees returning from leave without pay. The process detailed a list of actions, deadlines for the actions and who was to act. According to the policy, if an employee got vaccinated and submitted an attestation form to the manager to indicate the new status, this employee would be able to return to work from leave without pay.

Human Resources branch provided us with a list of 38 employees who returned to work from leave. We took a sample of 35 (92%) employees to validate (details in Appendix C: Sampling strategy). We reviewed the leave without pay list to confirm that the employees were part of the population of employees placed on administrative leave without pay. We also verified the employee’s name against the GC-VATS report to confirm that they received at least 1 vaccine dose before their return, as once an employee confirmed that they had received a vaccine dose they were eligible to return. The Policy on COVID-19 Vaccination for the Core Public Administration Including the Royal Canadian Mounted Police stated that, once an employee received their first vaccine dose, they have 10 weeks to receive their second dose or they would be placed on leave without pay.

We found that for 34 out of 35 samples, the employees were placed on administrative leave without pay due to their unvaccinated status and received at least 1 vaccine dose before their return to work. We also found all of the employees names on the My HRResource portal list which confirmed that the managers completed the return-to-work process.

It should be noted that of the 34 employees, we received evidence that:

• 16 were fully vaccinated and returned to work
• 9 had their accommodation request granted and allowed to return to work without vaccination
• 9 received the first vaccination dose and returned to work

Concerning the 9 employees who received the first vaccination dose and returned to work, based on the date of the dose we noted that 8 who received their first dose in order to return to work, would have been required to receive their second dose after the vaccination policy was suspended, thus out of the scope of this audit. In December 2021, 1 employee received their first dose, thus they would have been required to receive their second dose in February 2022. This individual would be included in our vaccination attestation validation testing population in which testing confirmed that all employees we sampled were fully vaccinated. As noted previously, the policy was suspended in June 2022, thus out of the scope of this audit.

For the 1 exception, we reviewed communication from the employee to their manager that they received their first dose but the attestation was not updated on GC-VATS and no further attestation evidence was provided. We concluded that this is not sufficient evidence to prove the employee’s partially vaccinated status prior to his return to work.

The 1 exception out of our sample of 35 resulted in an error rate of 2.9% which is below our threshold of 5%. When we extrapolated the 2.9% error rate across the population of 38 employees, we expect 1 exception.

Based on our findings, we concluded that overall Human Resources Branch had evidence to confirm that the operational processes and procedures for returning employees to work were adequately implemented and followed.

Methodology

The methodology for examination includes the following:

• the planning phase will include document collection and examination, as well as interviews with key stakeholders in the Human Resources Branch
• the examination phase will include testing of a sample of employee files (refer to Appendix C: Sampling strategy for details of the sample selection methodology)
• at the end of the examination phase, the audited organization will be requested to provide validation of the findings
• during the reporting phase, the audit team will document the audit findings, conclusions and recommendations in a Director's Draft Report
• this report will be internally cleared through the Office of the Chief Audit, Evaluation and Risk Executive quality assessment function
• the audited organization will be provided with the Director’s Draft Report and will be requested to review and comment on the report
• comments will be assessed and incorporated in the Chief Audit, Evaluation and Risk Executive's Draft Report
• this report will be sent to the audited organization for final acceptance
• a management response to the report, and a Management Action Plan in response to the audit recommendations, will be requested if applicable
• the Draft Final Report, management response, and Management Action Plan if applicable will be tabled at the Departmental Audit Committee meeting for final approval