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HomeMy WebLinkAboutStaff Report 2409-3430CITY OF PALO ALTO CITY COUNCIL Special Meeting Monday, September 23, 2024 Council Chambers & Hybrid 5:30 PM     Agenda Item     7.Approval of Two Audits as Recommended by the Policy & Services Committee: Public Safety Construction Audit and Parking Permit Technology Contracts Audit 5 3 9 9 City Council Staff Report From: City Manager Report Type: CONSENT CALENDAR Lead Department: City Auditor Meeting Date: September 23, 2024 Report #:2409-3430 TITLE Approval of Two Audits as Recommended by the Policy & Services Committee: Public Safety Construction Audit and Parking Permit Technology Contracts Audit RECOMMENDATION The Policy & Services Committee and Office of the City Auditor recommend City Council approve the results of two audits 1) Public Safety Construction Audit (Attachment A, P&S Committee recommended approval on June 11, 2024) and 2) Parking Permit Technology Contracts Audit (Attachment B, P&S Committee recommended approval on August 13, 2024). EXECUTIVE SUMMARY Public Safety Building Construction Audit Baker Tilly Advisory Group, LP (Baker Tilly), in its capacity serving as the Office of the City Auditor (OCA) for the City of Palo Alto (the City) performed construction audit services on the Public Safety Building project. The objectives of this audit were to verify that billings to the City from the Architect, Engineer, Inspector of Record, Construction Manager, Contractor, and Waterproofing Inspector were compliant with the terms of the applicable contracts. The new Public Safety Building will house the Police Department, 911 Emergency Dispatch Center, the Emergency Operations Center, the Office of Emergency Services, and the administration needs of the Fire Department. The Public Safety Building is part of the Capital Improvement (Infrastructure) Plan introduced in 2014. Non-compliance with contract terms related to project billings can result in cost overruns that impact the overall project budget. The audit found no material billing errors and did not recommend any additional actions. 5 3 9 9 Parking Permit Technology Contracts Management Audit Baker Tilly Advisory Group, LP (Baker Tilly), in its capacity serving as the Office of the City Auditor (OCA) for the City of Palo Alto (the City) performed an audit of the parking permit technology contract management process and controls based on the approved Task Order 4.16 in alignment with the FY 2022 citywide risk assessment and audit plan. The objectives of this review were to: 1) Determine whether adequate policies and procedures are implemented effectively to protect the privacy of personal information gathered using parking permit technology for the City’s parking management. 2) Determine whether the City monitors the parking permit vendor’s performance to ensure compliance with contract terms and applicable laws and regulations related to data privacy. The audit noted areas for improving policies and procedures related to how the City and it’s parking technology system third-party providers manage data privacy security. The attached report summarizes the analysis, audit findings, and recommendations. FISCAL/RESOURCE IMPACT For the Parking Permit Technology Contract Management audit, the OCA worked primarily with the Office of Transportation and the Information Technology Department, as well as, additional stakeholders, including the City Manager’s Office and the City Attorney’s Office, as necessary. The timeline for implementation of corrective action plans is identified within the attached report. The necessary resources to implement these recommendations will be dependent on the policy revisions approved upon completion of the review of IT policies and procedures. ENVIRONMENTAL REVIEW Council action on this item is not a project as defined by CEQA because the audit activities do not involve any commitment to any specific project which may result in a potentially significant physical impact on the environment. CEQA Guidelines section 15378(b)(4). ATTACHMENTS Attachment A: Public Safety Building Construction Audit Report, May 21, 2024 Attachment B: Park Permit Technology Contracts Audit, August 1, 2024 APPROVED BY: Kate Murdock, City Auditor 1 May 21, 2024 City of Palo Alto Office of the City Auditor Public Safety Building Construction Audit Report Contents Baker Tilly US, LLP, trading as Baker Tilly, is an independent member of Baker Tilly International. Baker Tilly International Limited is an English company. Baker Tilly International provides no professional services to clients. Each member firm is a separate and independent legal entity, and each describes itself as such. Baker Tilly US, LLP is not Baker Tilly International’s agent and does not have the authority to bind Baker Tilly International or act on Baker Tilly International’s behalf. None of Baker Tilly International, Baker Tilly US, LLP nor any of the other member firms of Baker Tilly International has any liability for each other’s acts or omissions. The name Baker Tilly and its associated logo is used under license from Baker Tilly International Limited. EXECUTIVE SUMMARY...................................................................................................1 INTRODUCTION...............................................................................................................2 AUDIT RESULTS..............................................................................................................4 APPENDICES...................................................................................................................5 1 Executive Summary Purpose of the Audit Baker Tilly US, LLP (Baker Tilly), in its capacity serving as the Office of the City Auditor (OCA) for the City of Palo Alto (the City) performed construction audit services on the Public Safety Building project. The objectives of this audit were to verify that billings to the City from the Architect, Engineer, Inspector of Record, Construction Manager, Contractor, and Waterproofing Inspector were compliant with the terms of the applicable contracts. Report Highlights Baker Tilly reviewed documentation provided by the Public Works Department for each of the selected scopes on a monthly basis through March 2024 and found project billings were compliant with the terms of the respective contracts. The billings, change orders, and additional services related to each scope had the proper supporting documentation and authorizations. During the audit, we identified several immaterial billing errors (see Finding 1 and Appendix A); however, these are considered minor when compared to the overall value of the costs reviewed. The results of this audit indicate the City’s implemented controls with respect to the review and approval of project billings are operating as intended. 2 Introduction 1 Invoiced amount includes design and construction administration services for the California Avenue Garage project. 2 Invoiced amount includes project development and construction management services for the Fire Station No. 3 and California Avenue Garage projects. Objective The objectives of this audit were to verify billings from the Architect, Engineer, Inspector of Record, Construction Manager, Contractor, and Waterproofing Inspector were contractually compliant, adequately supported, and authorized by the City. Background The new Public Safety Building will house the Police Department, 911 Emergency Dispatch Center, the Emergency Operations Center, the Office of Emergency Services, and the administration needs of the Fire Department. The Public Safety Building is part of the Capital Improvement (Infrastructure) Plan introduced in 2014. Non-compliance with contract terms related to project billings can result in cost overruns that impact the overall project budget. Scope Our testing scope encompassed billings and cost documentation provided by the Public Works Department through March 2024. This included the Swinerton Builders payment application dated December 31, 2023, and billings for the other scopes through February 2024. At that time, billings reviewed for each of the contract scope subject to audit were as follows: Scope Contractor Invoiced Amount Architect Ross Drulis Cusenbery (RDC) $ 9,497,8501 Engineer Romig Engineers 92,976 Inspector of Record 4Leaf, Inc. 546,534 Construction Manager Nova Partners, Inc. 9,264,4272 Contractor Swinerton Builders 86,888,316 Waterproofing Inspector Consolidated Engineering Laboratories (CEL) 106,317 Total $ 106,396,420 Methodology and Analysis To achieve the audit objectives, Baker Tilly performed the following procedures and analysis: •Inspected the contract to identify the key terms related to project billings for each scope subject to audit •Analyzed billings for each scope subject to audit on a monthly basis as follows: o Created control schedules for billings and payment applications o Footed and recalculated amounts billed to test for mathematical accuracy o Rolled forward previous billed amounts to ensure reported totals were accurate o Verified lien waivers were collected where applicable o Verified monthly invoices were submitted with a description of services performed and the applicable charges (identification of personnel, hours worked, hourly rates, and reimbursable expense) o Where applicable, verified hourly rates reconciled to agreed upon rates o Where applicable, reconciled support for reimbursable expenses to third party cost support 3 INTRODUCTION 3 Government auditing standards require an external peer review at least once every three (3) years. The last peer review of the Palo Alto Office of the City Auditor was conducted in 2017. The Palo Alto City Council approved a contract from October 2020 through June 2022 with Baker Tilly US, LLP (Baker Tilly) and appointed Kyle O’Rourke, Senior Consulting Manager in Baker Tilly's Public Sector practice, as City Auditor. Given the transition in the City Audit office, a peer review was not conducted in 2020 and will be conducted after the third year of Baker Tilly’s contract. o Verified aggregate billings did not exceed contractual limitations o Verified billings and payment applications had the appropriate authorizations •Analyzed change orders, amendments, and additional services in scope as follows: o Reconciled the amounts reflected on change orders to supporting documentation o Verified the change order costs were contractually compliant and reconciled to agreed upon rates where appliable o Recalculated any markups and insurance amounts to ensure the applicable rates adhered to the contract terms o Verified change orders and additional services had the required authorization •Communicated the testing results to the Public Works Department on a monthly basis: o Verified any identified billing errors were corrected (see Appendix A) o Requested additional documentation as necessary to complete testing Compliance Statement This audit activity was conducted from March 2021 to March 2024 in accordance with generally accepted government auditing standards, except for the requirement of an external peer review3. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Organizational Strengths During this audit activity, we observed that the controls implemented by the City related to the review of billings and change orders were operating as intended. This is evidenced based on the low occurrence of findings and immaterial values thereof. All parties were accommodating during the audit process and were forthcoming with answers to questions and requests for additional documentation. The Office of the City Auditor greatly appreciates the support of the Public Works Department in conducting this audit activity. Thank you! 4 Audit Results Finding 1: Immaterial billing errors Baker Tilly identified nine billing errors totaling $10,122 throughout the audit engagement. These errors were mostly related to labor billing rate errors where the contractor in question billed for services at rates that were not compliant with the agreed upon rates. Each of the identified errors was resolved on a subsequent billing from the applicable contractor. See Appendix A for additional detail related to the specific billing errors identified. Recommendation No additional action is required. All billing errors have been resolved. In addition, the errors in question occurred during the early months of our audit and the occurrence of findings decreased as the audit progressed. Recommended follow-up activities As of the report date the project was not yet complete. Baker Tilly recommends performing a closeout audit upon final completion of the project. The current substantial completion is anticipated on July 31, 2024. The closeout audit would kick off in August 2024 and conclude upon receipt of the documentation required to complete closeout testing. The primary objectives of the closeout audit would include: •Analyze billings and change orders for the selected audit scopes received by the Public Works Department from March 2024 through project completion (Swinerton Payment applications subsequent to December 31, 2023, and billings from the other selected scopes subsequent to February 2024). •Verify the allowances included in the construction contract are reconciled and closed out per the contract terms •Verify final lien waivers are collected from subcontractors •Confirm final amounts paid to each contractor in the scope of the audit does not exceed the contractual limitations 5 Appendices Appendices 6 Appendix A: Public Safety Building – Construction Audit Issues Log The following audit issues totaling $10,122 were identified during monthly testing. Each of these issues were communicated to the Public Works Department when identified. All audit issues have been resolved. AI ID No.Audit Issue AI Date Response Date Status Result Amount 001 Swinerton Builders - COR #25 which was included in Change Order #4 included a duplicate charge for equipment markup totaling $356.77 (see RFI #7). 9/23/2021 11/15/2021 Closed Public Works provided Change Order #8 reflecting the credit. Baker Tilly reviewed Change Order #8 and confirmed credit. $ 356.77 002 Nova Partners - Invoices from June 2017 to December 2017 billed an Estimator at a rate of $175 per hour rather than the agreed-upon rate of $160 per hour. This resulted in a billing rate overcharge totaling $6,975 (see RFI #1). 10/15/2021 1/12/2022 Closed Public Works provided Invoice #104376 reflecting the credit. Baker Tilly reviewed Invoice #104376 and confirmed credit. $ 6,975.00 003 Consolidated Engineering Laboratories - Invoice #191863 billed overtime at a rate of $161.25 and double-time at a rate of $215.00 rather than the agreed upon rates of $142.50 for overtime and $190 for double time. This resulted in a billing rate overcharge totaling $400 (see RFI #24). 3/16/2022 4/13/2022 Closed Public Works provided Invoice #195679 reflecting the credit. Baker Tilly reviewed Invoice #195679 and confirmed credit. $ 400.00 004 Romig Engineers - Invoice #27139 and #28131 billed the position "Engineering Technician Prevailing Wage" at a rate of $150 per hour rather than the agreed-upon rate of $144 per hour. This resulted in a billing rate overcharge totaling $473.40 (see RFI #27). 4/21/2022 5/31/2023 Closed Public Works provided Invoice #31394 and #31569 reflecting the credit. Baker Tilly reviewed Invoice #31394 and #31569 and confirmed credit. $ 473.40 Appendix A: Public Safety Building – Construction Audit Issues Log (cont.) 7 AI ID No.Audit Issue AI Date Response Date Status Result Amount 005 Romig Engineers - Invoice #28131 billed overtime at a rate of $225 rather than the agreed upon rate of $216. This resulted in a billing rate overcharge totaling $63.00 (see RFI #28). 4/21/2022 5/31/2023 Closed Public Works provided Invoice #31569 reflecting the credit. Baker Tilly reviewed Invoice #31569 and confirmed credit. $ 63.00 006 Romig Engineers - Invoice #27784B billed the position "Engineering Technician Prevailing Wage" at a rate of $150 per hour rather than the agreed-upon rate of $144 per hour. Overtime was also billed at a rate of $225 rather than the agreed upon rate of $216. This resulted in a billing rate overcharge totaling $333.00 (see RFI #26). 4/21/2022 5/31/2023 Closed Public Works provided Invoice #31394 reflecting the credit. Baker Tilly reviewed Invoice #31394 and confirmed credit. $ 333.00 007 Consolidated Engineering Laboratories (CEL) Invoice #196433 billed the position "Waterproof Inspector" at rate of $99.28 per hour rather than the agreed-upon rate of $96.90 per hour. This resulted in a billing rate overcharge totaling $310.59 (see RFI #31). 6/27/2022 7/26/2022 Closed Public Works provided Invoice #198423 reflecting the credit. Baker Tilly reviewed Invoice #198423 and confirmed credit. $ 310.59 008 Consolidated Engineering Laboratories (CEL) Invoice #197348 billed the position "Waterproof Inspector" at rate of $99.28 per hour rather than the agreed-upon rate of $96.90 per hour. This resulted in a billing rate overcharge totaling $166.60 (see RFI #35). 7/26/2022 7/26/2022 Closed Public Works provided Invoice #198423 reflecting the credit. Baker Tilly reviewed Invoice #198423 and confirmed credit. $ 166.60 Appendix A: Public Safety Building – Construction Audit Issues Log (cont.) 8 AI ID No.Audit Issue AI Date Response Date Status Result Amount 009 4 Leaf, Inc - Invoice #J3909W billed time for Traci Craton at $169.95 per hour rather than the agreed-upon rate of $54 per hour. This resulted in a billing rate overcharge totaling $1,043.64 (See RFI #42). 7/28/2023 8/29/2023 Closed Public Works provided Invoice #J309X- REV reflecting the correct rates. Baker Tilly reviewed Invoice #J309X- REV and confirmed. $ 1,043.64 9 10 1 August 1, 2024 City of Palo Alto Office of City Auditor Parking Permit Technology Contracts Audit Contents Baker Tilly US, LLP, trading as Baker Tilly, is an independent member of Baker Tilly International. Baker Tilly International Limited is an English company. Baker Tilly International provides no professional services to clients. Each member firm is a separate and independent legal entity, and each describes itself as such. Baker Tilly US, LLP is not Baker Tilly International’s agent and does not have the authority to bind Baker Tilly International or act on Baker Tilly International’s behalf. None of Baker Tilly International, Baker Tilly US, LLP nor any of the other member firms of Baker Tilly International has any liability for each other’s acts or omissions. The name Baker Tilly and its associated logo is used under license from Baker Tilly International Limited. EXECUTIVE SUMMARY...................................................................................................1 PURPOSE OF THE AUDIT......................................................................................................................1 REPORT HIGHLIGHTS............................................................................................................................1 INTRODUCTION...............................................................................................................5 DETAILED ANALYSIS...................................................................................................11 BEST PRACTICES..................................................................................................................................12 AUDIT RESULTS............................................................................................................13 ..................................................................................................................................................................24 1 Executive Summary Purpose of the Audit Baker Tilly US, LLP (Baker Tilly), in its capacity serving as the Office of the City Auditor (OCA) for the City of Palo Alto (the City), conducted an audit of the parking permit technology systems contract management process and controls based on the approved Task Order 4.16. The objectives of this review were to: 1) Determine whether adequate policies and procedures are implemented effectively to protect the privacy of personal information gathered using parking permit technology for the City’s parking management. 2) Determine whether the City monitors the vendor’s performance to ensure compliance with contract terms and applicable laws and regulations related to data privacy. Report Highlights Finding 1: Data Privacy Improvements The City lacks a data privacy program owner and policies, procedures and associated training requirements have not been regularly updated. Key Recommendation We recommend the City designate a data privacy program owner to coordinate a uniform approach to data privacy management between the City Attorney, Chief Information Officer, and Director of Human Resources. Finding 2:Lack of Personal Identifiable Information (PII) Procedures The City does not have Personal Identifiable Information (PII) procedures for personal information that is managed or collected. Additionally, there are no procedures related to masked or de-identified personal information. Key Recommendation We recommend that the City establish procedures for managing and collecting Personal Identifiable Information (PII). These procedures should include: classification of information, retention of PII, access control, data masking, and data restoration and backup. Finding 3:Records and Information Management Policy Enhancements The City's Records and Information Management Policy does not address essential elements related to information collection consent, management protocols for personally identifiable information (PII), and comprehensive guidelines governing data retention, maintenance, and destruction. Key Recommendation We recommend the City should annually review and approve its Records and Information Management Policy to ensure it aligns with best practices and relevant laws. 2 EXECUTIVE SUMMARY Finding 3: Lack of User Access Listing and Reviews The City could not provide a user access listing for individuals who have access to Personal Identifiable Information (PII) and there are no individuals that are considered data security owners. Additionally, there is no evidence that access reviews are being performed periodically by data security owners and confirmed with the IT Department. Key Recommendation We recommend that the City establishes a list of individuals who have access to add, edit, or delete Personal Identifiable Information (PII). Finding 4: Inadequate Breach of Contract Terms and Conditions with Third-Party Vendor There is a section called "Data Security Breach Notification Act" within the City's Data Privacy Policy, however, there is no specific mention of breaches related to third-party vendors. Key Recommendation We recommend that the City's Data Privacy Policy explicitly covers breaches that occur to third-party vendors. The policy should specifically emphasize that vendors are required to adhere to and uphold the data privacy and security standards set by the City. Finding 5:Inadequate Vendor Performance Assessment There is no formal vendor performance assessment in place within the Transportation Department. Key Recommendation We recommend that the Transportation Department establishes a formal vendor performance assessment for all third-party vendors. Finding 6:Absence of Third-Party Agreement Requirements The City’s third-party license plate reading provider agreement does not formally define the minimum requirements and vendor expectations related to the workflows that process PII data. Key Recommendation The City should implement internal controls to ensure that all third-party providers and agreements are in alignment with Palo Alto's maximum risk appetite and risk posture. 3 Introduction Objective The objectives of this review were to: 1) Determine whether adequate policies and procedures are implemented effectively to protect the privacy of personal information gathered using PARKING PERMIT technology for the City’s parking management. 2) Determine whether the City monitors the vendor’s performance to ensure compliance with contract terms and applicable laws and regulations related to data privacy. Background During the FY2022 risk assessment, the Baker Tilly team identified the following inherent risks and noted the contract management as a high-risk area: •Contract compliance and cost control issues •Noncompliance with applicable data privacy laws 4 INTRODUCTION The summary of the information provided in the FY2022 operating and capital budget documents prepared by the City of Palo Alto (the City) is as follows: Systems Involved •Permitting System, City of Palo Alto •Processing System, Duncan Solutions •Automated License Plate Reader, ComSonics Risk Consideration Based on the currently available information, we have identified the following risks associated with management of the Office of Transportation: •Data Privacy •Contract Management •Safety Improvement Projects •Traffic Operations 5 INTRODUCTION Personally Identifiable Information (PII) According to the National Institute of Standards and Technology (NIST), the definition of personally identifiable information (PII) is: "Information that can be used to distinguish or trace an individual’s identity—such as name, social security number, biometric data records—either alone or when combined with other personal or identifying information that is linked or linkable to a specific individual (e.g., date and place of birth, mother’s maiden name, etc.)." It is crucial for the City to define their posture as it relates to data privacy and PII because this will allow the City to ensure that all providers are complying with the City’s standards. Data Security Owner Each data security owner (the City, Duncan Solutions, and ComSonics) is responsible for the classification, protection, storage, use, and quality of data processed related to parking permitting and enforcement operations. Data Life Cycle At a high level, the data life cycle involves the suggested steps below, followed by Palo Alto’s current, related practices: 1. Data Collection: Data should be gathered in standardized formats, so it can be accessible and manageable later in the cycle. •Palo Alto customers apply for permits online, which includes PII and PCI. 2. Data Storage Policies should be established related to the storage of data. •Data is stored in the City’s permitting system, Duncan Solutions’ 6 INTRODUCTION processing system, and the ComSonics system. 3. Data Maintenance Data should be made usable and available for the appropriate person(s). •Palo Alto’s customer application data is used to generate permits. 4. Data Usage Data is used for making decisions. •Verification of active permits is performed by scanning license plate numbers into the parking permit system and validating against Duncan Solutions’ processing system, which pulls from the City’s permitting system. 5. Data Cleaning When data is no longer useful, data should be deleted, purged, destroyed, or archived. •Palo Alto customers permits that are inactive or expired should be purged based on the City’s records retention schedule. Scope The scope of this audit was to review the parking permit technology systems contract management. The OCA reviewed the City of Palo Alto’s policies and procedures related to Privacy Management, Data Management and Collection, Data Security, 3rd Party C&C Agreements, Surveillance Policy, and Incident Management in relation to the use of the parking permit technology and to ensure that the City maintains all necessary policies and that they are up to date. In addition to the policies and procedures, the OCA reviewed the City’s vendor performance monitoring. 7 INTRODUCTION 1 Government auditing standards require an external peer review at least once every three (3) years. The last peer review of the Palo Alto Office of the City Auditor was conducted in 2017. The Palo Alto City Council approved a contract with Baker Tilly U.S, LLP for internal audit services for October 2020 through June 2022 with an extension through June 2025. City Council appointed Kate Murdock, Audit Manager in Baker Tilly’s Risk Advisory practice, as City Auditor in May 2024. As a result of transitions in the Audit Office and peer review delays due to the COVID pandemic, an external peer review is targeted for 2025. It should be noted that Baker Tilly’s most recent firmwide peer review was completed in October 2021 with a rating of “Pass”. The scope of that peer review includes projects completed under government auditing standards. A report on the next firmwide peer review should be available later in 2024. Methodology 1. In order to address our audit objective (1), we performed the following procedures: •Interviewed the appropriate individuals to understand the process, the information system used, and internal controls related to the gathering of personal information collected by the parking permit technology systems. •Reviewed the contracts, policies, and procedures as well as the regulations and standards to identify the criteria to be used for evaluation of compliance and control design and effectiveness. •Reviewed the documents (such as contracts and supporting documents for allocation) for selected samples. •Compared privacy control against the California Consumer Privacy Act of 2018 and other best practices. 2. In order to address our audit objective (2), we performed the following procedures: •Interviewed the appropriate individuals to understand the process and internal controls over compliance with contracts, regulations, and vendor monitoring. •Reviewed agreements between Palo Alto and Duncan Solutions to identify compliance requirements. •Identified the monitoring activities performed by management to ensure the compliance. •Reviewed the relevant documents to evaluate the effectiveness of compliance monitoring activities. Compliance Statement This audit activity was conducted from February 2023 to December 2023 in accordance with generally accepted government auditing standards, except for the requirement of an external peer review1. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Organizational Strengths During this audit activity, we observed certain strengths of the City. Key strengths include: •Transportation Department was responsive and helpful. •All involved departments provided responses to all requested items. •Knowledge and expertise of third-party providers. 8 INTRODUCTION The Office of the City Auditor greatly appreciates the support of the Information Technology, Human Resources, and Transportation Departments in conducting this audit activity. Thank you! 9 Detailed Analysis 2 California Consumer Privacy Act of 2018, Section 1798.185 - Codes Display Text (ca.gov) 3 Chapter 3 – Rights of the data subject - General Data Protection Regulation (GDPR) (gdpr-info.eu) 4 A complete guide to business Records Retention | Iron Mountain United States Policies and Procedures The City has the Data Privacy Policy (Revised: April 2019). The Policy Statement of this policy is “this Data Privacy Policy describes the data privacy requirements and procedures for the protection of personal data and personal information of individuals (the “Data”) created, collected, processed, received, stored, and transmitted by the City of Palo Alto (the “City”).” The City’s Data Privacy Policy includes User Data Collected, Stored, Processed, and Shared; Information Security and Data Protection; Data Security Breach Notification Act; Third-Party Data Access Control; Information Disclosure; California Privacy Rights; Protecting Children’s Privacy Online; and City of Palo Alto Utilities (“CPAU”) Data Privacy. The policy does not include the following related best practices: •Guidance on the measures in place to secure and protect PII from unauthorized access, disclosure, alteration, and destruction. This may include encryption, access controls, and regular security audits.2 •A clear definition of Data Subject Rights that outlines the rights of individuals regarding their personal information3. The City has the Records and Information Management Policy (Revised: July 2000). The policy statement of this policy is that it “was developed to ensure the efficient retention and protection of information and to assure the availability of information to the public in accordance with the State of California Public Records Act.” The City’s Records and Information Management Policy includes Roles and Responsibilities and a Compliance Requirements section. The policy does not include the following related best practices4: •A formal definition of record categories or types of data that guides how data is retained. •A procedure for destroying or disposing of records once they have reached the end of their retention period. •A procedure for exceptions and legal holds as records may be exempt from regular retention periods. •Guidance on individuals that have access to the various types of records. •Guidance on any training programs or awareness campaigns that are related to record retention. •Guidance on the monitoring of record retention activity and consequences of non-compliance. There is also a Data Retention Schedule that supplements the Records and Information Management Policy. The retention schedule identifies which records are permanently retained as well as department-specific retention of records. 10 DETAILED ANALYSIS Best Practices As organizations and businesses move online and communicate digitally, the risk of data breaches and/or private information leaks are higher than ever. Personally identifiable information (PII) can be used for targeted attacks, social engineering attacks, identity theft, and more. Effective and updated policies and procedures are integral to protecting the City from breaches of PII. Through researching standards related to PII, data privacy, and records management & retention, the OCA compiled the following list of best practices according to the California Consumer Privacy Act (CCPA), the Information Systems Audit and Control Association (ISACA), and National Institute of Standards and Technology (NIST). •Educate and train employees on a consistent basis on topics related to PII, data privacy, security, incident management, and cybersecurity. •Obtain explicit and informed consent from individuals before collecting their personal information. •The purposes for which personal data are collected should be specified at the time of data collection. •Personal data should be protected by reasonable security safeguards against such risks as loss or unauthorized access, destruction, use, modification, or disclosure of data. •Conduct periodic data audits and/or risk assessments to identify vulnerabilities, compliance gaps, and areas for improvement. •Review policies and procedures on an annual basis to ensure accuracy and that all information is up to date. •Ensure that all policies and procedures related to PII, data privacy, and security are available for City employees and external users. The vendor contract owner should be responsible for all quantitative and qualitative key performance indicator identification, monitoring and reporting to Executive Leadership related to but not limited to the following: •Quality - error resolution •Delivery - availability •Innovation - proposed improvements •Risk - breaches and non-compliance •Cost - price increase and scope limitations •Customer Service - compliant resolution and communication 11 Audit Results Finding 1: Data Privacy Improvements The City lacks an identified citywide data privacy program owner and policies, procedures and associated training requirements have not been updated recently. Recommendation We recommend the City designate a data privacy program owner to coordinate a uniform approach to data privacy management among the City Attorney, Chief Information Officer and Director of Human Resources. Based on best practices, the data privacy program owner responsibilities should include the following: •Annual review and update of data privacy policies and procedures in alignment with the California Consumer Privacy Act of 2018. Reviews should be appropriately documented. •Annual data privacy trainings held with all departments. The City might also consider use of a Certified Information Privacy Professional (CIPP) to ensure compliance with data privacy laws, regulations, and best practices. Training compliance should be tracked and monitored, and metrics might include: completion rate, assessment scores, feedback, and survey responses, and reported to management quarterly. Every employee is expected to take privacy management training. •Ensure data privacy requirements and changes are annually incorporated into the City’s Record and Information Retention Policy so records containing personal identifiable information are properly secured. Additionally, documented procedures for data destruction should be aligned with legal requirements, Management Response Responsible Department(s): Information Technology Concurrence: Agree Target Date: CY Q4 2024 Action Plan: While the City Does not have a designated data privacy program owner, the Data Privacy Policy provides oversight for the shared responsibility amongst the roles and departments, though staff agree the policy review and updates. A project to update all IT policies has been initiated and this policy will be reviewed as part of this project, specifically in alignment with NIST regulations. This initiative has been started in alignment with the Cybersecurity Audit that recommended review of Outdated Policy and Standards Documentation recently completed in FY 2023. Although cybersecurity training is already offered and required citywide, to provide privacy training opportunities, a newly procured security training platform will provide training related to data protection, compliance with privacy laws and regulations, and best practices related to data privacy. Finding 2: Lack of Personal Identifiable The City does not have specific Personal Identifiable Information (PII) procedures for personal information that is managed or collected in 12 Information (PII) Procedures the parking permit systems. In addition, there are no procedures or guidelines regarding if or which information should be de-identified to protect information privacy. Recommendation We recommend when implementing a system such as the parking permit systems, that the City documents procedures related to Personal Identifiable Information (PII) when managing or collecting personal data in that system. Procedures for PII data should include how to classify sensitive and non-sensitive information, which PII is necessary for retention, access control, data masking (what type of data is redacted or even replaced), contract terms to manage vendor relationships where PII is referenced or shared, and data that is restored or backed up. Once established the procedures should be easily accessible to program staff. Management Response Responsible Department(s): Information Technology Concurrence: Partially Agree Target Date: CY Q4 2024 Action Plan: Procedures on handling PII are included and maintained as part of Information Privacy policy provided for review. In addition, a Surveillance Policy is also maintained and reported on annually for new technologies implemented prospectively. Specifically, parking permit data is limited to parking permit program and collections staffing. More specificity regarding PII handling can be added and identified in these policies already under review. Finding 3: Lack of User Access Listing and Reviews The City did not provide a user access listing for individuals who have access to Personal Identifiable Information (PII) for the parking permit systems and no designation of the data security owner(s). Additionally, there is no evidence that access reviews are being performed periodically. Recommendation We recommend that the City establishes a list of individuals who have access to add, edit, or delete Personal Identifiable Information (PII). The City should review user access rights annually by the identified data security owners in departments. Management Response Responsible Department(s): Information Technology Concurrence: Agree Target Date: CY Q4 2024 Action Plan: Vendors required to supply role-based access control to managed user access levels and those permissions/restrictions are established upon user set-up. Staff will evaluate updates to centralized process requirements in the review of data privacy policy and procedures including feasibility to develop reports will be shared with the appropriate staff to validate only authorized staff have access to PII across many software platforms. 13 Finding 4: Inadequate Breach of Contract with Third-Party Vendor There is a section called "Data Security Breach Notification Act" within the City's Data Privacy Policy, however, there is no specific mention of breaches related to third-party vendors. Recommendation We recommend that the City's Data Privacy Policy explicitly covers breaches that occur to third-party vendors. The policy should specifically emphasize that vendors are required to adhere to and uphold the data privacy and security standards set by the City. Additionally, the policy should specify that third-party vendors must follow the City's data classifications and requirements. The City's data breach response plan should identify a key point of contact, defined approved communication methods, the maximum timeframe for which the incident should be communicated to the City, and the minimum requirements for key information that should be provided. Management Response Responsible Department(s): Information Technology Concurrence: Partially Agree Target Date: CY Q4 2024 Action Plan: All vendors are required to agree to the City's Cybersecurity Terms and Conditions which requires notification of a security breach, this is evidenced by the ALPR contract approved in 2021 which included these terms. Specific updates to specify a response plan expectations in the policy will be reviewed as part of the project to update all IT policies as staff agreed the policy is in need of review and update. Finding 5: Inadequate Vendor Performance Assessment The City does not have a formal process to ensure on-going vendor compliance with the Vendor Information Security Assessment (VISA) Questionnaire through the full term of the parking permit systems contracts. Recommendation We recommend that the Transportation Department establish a formal vendor performance assessment for all third-party vendors. This assessment would help evaluate potential risks, identify benefits of working with a vendor, and confirm that the vendor is fulfilling the terms of the contract while delivering value in the relationship. Specific tests that can be performed during a third-party assessment are performance tests, delivery tests, customer service tests, cybersecurity tests, and compliance tests. Management Response Responsible Department(s): Information Technology, Office or Transportation, Administrative Services Concurrence: Partially Agree Target Date: Q4 CY 2024 Action Plan: 14 The Office of Transportation is responsible for contract management and has an informal process to ensure service providers are meeting scope of services described within. A more formal process to ensure continued compliance with cyber security requirements through the term of the contract will be reviewed among Administrative Services, Office of Transportation, and Information Technology to determine an appropriate procedure. Staff is reviewing this in alignment with the IT risk management process which was recommended as part of the Risk Management Assessment completed by Baker Tilly previously. Finding 6: Absence of Third-Party Agreement Requirements The City’s third-party license plate reading provider agreement does not formally define the minimum requirements and vendor expectations related to the workflows that process PII data. Recommendation The City should implement internal controls to ensure that all third- party providers and agreements are in alignment with the Palo Alto's maximum risk appetite and risk posture in the following areas: •Contractual language for the management of that have access to City PII data. •Duly executed contracts are in place with third parties managing or that have access to workflows related to PII data. •Third-party companies responsible for or that have access to workflows which are related to PII are appropriately risk ranked in order to assess exposure to privacy data leakage. •Self-assessment of third-party vendors is managed and reviewed to ensure performance is satisfactory. Management Response Responsible Department(s): Information Technology & Administrative Services Concurrence: Partially Agree Target Date: Q4 CY 2024 Action Plan: The City currently has a procurement process that involves the requesting department, legal review, and consultation with stakeholders such as Information Technology or Human Resources. This process will be detailed in the nearly completed Procurement Audit. Standard contract templates that are in alignment with the City’s risk tolerance levels are used when possible, when changes or alternative contract documents are necessary they are reviewed by these parties in depth to ensure general compliance with risk exposure. As such, this continues to be a living process as both service providers and industry standard practices evolve; staff agree that as more technology contracts are required for the delivery of services, clarity in risk tolerance and alignment with contract terms will continue to be adjusted. 15