REPORT DIGEST

OFFICE OF THE STATE FIRE MARSHAL

COMPLIANCE EXAMINATION
FOR THE TWO YEARS ENDED JUNE 30, 2020

Release Date:  November 30, 2021

FINDINGS THIS AUDIT:  21

CATEGORY:  NEW -- REPEAT -- TOTAL
Category 1:  8 -- 8 -- 16
Category 2:  3 -- 2 -- 5
Category 3:  0 -- 0 -- 0
TOTAL:  11 -- 10 -- 21

FINDINGS LAST AUDIT: 12

Category 1: Findings that are material
weaknesses in internal control and/or
a qualification on compliance with
State laws and regulations (material
noncompliance).
Category 2: Findings that are
significant deficiencies in internal
control and noncompliance with State
laws and regulations.
Category 3: Findings that have no
internal control issues but are in
noncompliance with State laws and
regulations.

State of Illinois, Office of the
Auditor General
FRANK J. MAUTINO, AUDITOR GENERAL

To obtain a copy of the Report
contact:
Office of the Auditor General, Iles
Park Plaza, 740 E. Ash Street,
Springfield, IL 62703
(217) 782-6046 or TTY (888) 261-2887

This Report Digest and Full Report are
also available on the worldwide web at
www.auditor.illinois.gov

INTRODUCTION

Because of the significance and
pervasiveness of the findings
described within the report, we
expressed an ADVERSE OPINION on the
Office of the State Fire Marshal’s
compliance with the specified
assertions which comprise a State
compliance examination. The
Codification of Statements on
Standards for Attestation Engagements
(AT-C § 205.72) states a practitioner
“should express an adverse opinion
when the practitioner, having obtained
sufficient appropriate evidence,
concludes that misstatements,
individually or in the aggregate, are
both material and pervasive to the
subject matter.”
SYNOPSIS

• (20-01) The Office did not perform
all inspections of public schools or
always report identified violations to
the regional superintendents.

• (20-02) The Office did not perform
all inspections requested by licensing
agencies in a reasonable timeframe.
• (20-03) The Office failed to
implement an adequate enforcement
program to ensure compliance with the
Elevator Safety and Regulation Act.

• (20-12) The Office did not exercise
adequate controls over its collection
and revenue recognition of fees.

FINDINGS, CONCLUSIONS, AND
RECOMMENDATIONS

FAILURE TO PERFORM SCHOOL FIRE
INSPECTIONS OR REPORT VIOLATIONS

The Office of the State Fire Marshal
(Office) did not perform all
inspections of public schools or
always report identified violations to
the regional superintendents
(superintendent).

During testing, we noted the
following:

• The Office did not perform annual
fire safety inspections of each public
school within the State. We noted
1,218 of 3,461 (35%) and 1,248 of
3,447 (36%) schools were not inspected
during Fiscal Year 2019 and Fiscal
Year 2020, respectively.

• Due to insufficient documentation,
we were unable to determine whether 1
of 60 (2%) inspections selected for
testing was performed and whether
violations were submitted to the
superintendent, if violations were
noted.

• The Office did not have sufficient
controls in place to ensure violations
identified during school inspections
performed by qualified fire officials
to whom the Office delegated its
authority during the examination
period were sent to the superintendent
within 15 days of the completed
inspection. More specifically, all of
the school inspection reports are
entered into the Office’s Fire
Prevention System (Mobile Eyes), and
once approved, the report is
automatically emailed to the
superintendent. The Office does not
monitor the time between the date of
inspection and when the inspection
report is entered into Mobile Eyes.

• Forty-eight of 60 (80%) sampled
inspections of public schools
conducted by the Office during the
examination period contained
violations noted by the inspector. For
those 48 inspections containing
violations, we noted the following:

– Seventeen (35%) reports with
violations did not have evidence the
report had been submitted to the
superintendent.

– Six (13%) reports with violations
were reported to the superintendent
between 3 and 26 days late. (Finding
1, pages 12 – 14)

We recommended the Office work with
the Governor and the General Assembly
to ensure sufficient resources exist
to timely conduct public school
building inspections. Further, the
Office should enhance its internal
controls to provide assurance
violation reports are timely sent to
the school’s applicable
superintendent.

The Office agreed with the
recommendation.

FAILURE TO PERFORM TIMELY LICENSING
INSPECTIONS AT CHILD CARE FACILITIES
AND COMMUNITY-INTEGRATED LIVING
ARRANGEMENTS

The Office did not perform all
inspections requested by licensing
agencies in a reasonable timeframe.
The Office is required to provide the
necessary fire inspections for
agencies under various licensing acts.
The Office receives requests for
inspections directly from the
licensing agency through the Fire
Prevention System.

During testing, we noted the
following:

• Department of Children and Family
Services per the Child Care Act of
1969 (225 ILCS 10/5.7), were not
performed on a timely basis from the
date the request was received by the
Office from the licensing agency.
Inspections were performed between 1
and 134 days after the reasonable 60
day turnaround time as determined by
the auditor.

• Eighteen of 60 (30%) inspections
selected for testing of Community-
Integrated Living Arrangements,
requested by the Department of Human
Services per the Community-Integrated
Living Arrangements Licensure and
Certification Act (210 ILCS
135/13(b)), were not performed on a
timely basis from the date the request
was received by the Office from the
licensing agency. Inspections were
performed between 7 and 162 days after
the reasonable 60 day turnaround time
as determined by the auditor.

Additionally, after the accountants
performed their sample testing, Office
management stated it had a backlog of
1,339 requested fire prevention
inspections (not counting schools or
prisons) as of June 30, 2020. (Finding
2, pages 15 – 16)

We recommended the Office work with
the Governor and the General Assembly
to ensure sufficient resources exist
to timely conduct facility licensing
inspections.

The Office agreed with the
recommendation.

INADEQUATE ENFORCEMENT PROGRAM

The Office failed to implement an
adequate enforcement program to ensure
compliance with the Elevator Safety
and Regulation Act (Act).

The Act (225 ILCS 312/105) states it
is the Office's responsibility to
develop an enforcement program to
ensure compliance with the rules and
requirements referenced in the Act.
The Office codified its rules
governing the enforcement of the
program in the Illinois Administrative
Code (Code) (41 Ill. Admin. Code
1000). The Code (41 Ill. Admin. Code
1000.150) requires the owner of the
conveyance system to apply annually
for a certificate of operation. Along
with the application, the owner is
required to provide to the Office a
copy of the most recent annual
inspection indicating the system has
passed inspection by a licensed
elevator inspector.

During our testing of the timeliness
of conveyance inspections, we noted 15
of 60 (25%) selected conveyance
systems did not have an annual
inspection performed on them as
required by the Code (41 Ill. Admin.
Code 1000.140). Furthermore, after
noting the lack of inspections, we
requested the Office run a detailed
report (dated May 14, 2021) to
document all active conveyance systems
under the Office’s jurisdiction which
had expired certificates of
operations. The report showed 3,999 of
14,282 systems had expired
certificates of operation.

Based on the lack of inspections and
the number of systems with expired
certifications of operation, we
determined the Office has not
implemented an adequate enforcement
program to ensure compliance with the
Act. (Finding 3, pages 17 – 18)

We recommended the Office implement an
adequate enforcement program to ensure
compliance with the Elevator Safety
and Regulation Act. In addition, we
recommended the Office work with the
Governor and the General Assembly to
ensure sufficient resources exist to
adequately review and approve
certifications applied for by owners
of conveyance systems.

The Office partially agreed with the
recommendation and noted they believed
the enforcement program to be
adequate; however, the Office lacked
sufficient resources to ensure
compliance.

INADEQUATE CONTROLS OVER FEES

The Office did not exercise adequate
controls over its collection and
revenue recognition of fees.

During testing, we noted the
following:

• During our review of the Office’s
process for collecting inspection fees
for boilers and pressure vessels, we
noted the Office lacked an adequate
process for identifying the party
responsible for paying the fee.

• For all remaining fees, the Office
did not refer any of its delinquent
accounts receivable to the Department
of Revenue’s Debt Collection Bureau.

• The Office was unable to provide
supporting documentation to
substantiate the $1.662 million net
accounts receivable balance reported
in the Fiscal Year 2019 Fourth Quarter
Quarterly Summary of Accounts
Receivable - Accounts Receivable
Activity (Form C-97), Quarterly
Summary of Accounts Receivable - Aging
of Total Gross Receivables (Form
C-98), and Quarterly Summary of
Accounts Receivable - External
Collections Activity for Accounts Over
180 Days Past Due (Form C-99).
(Finding 12, pages 42 – 44)

We recommended the Office implement
controls to obtain sufficient
information about responsible parties
to enable the collections of accounts
receivable, or seek a legislative
remedy to require up-front payment for
an inspection at the time when an
inspection is scheduled. Further, the
Office should refer qualifying debt to
the Bureau for external collection
efforts. Finally, we recommended the
Office implement additional procedures
as necessary to ensure adequate
supporting documentation is maintained
to substantiate its reporting of
receivables.

The Office agreed with the
recommendation.

OTHER FINDINGS

The remaining findings pertain to
inadequate controls over high pressure
boiler inspections, monthly
reconciliations and expenditure
records, employee personnel files and
payroll expenditures, contractual and
interagency agreements, receipts,
grant agreements, travel, state
vehicles, state property, performance
evaluations, and missing IT equipment;
lack of an interagency agreement with
the Department of Public Health;
failure to establish and maintain a
Statewide arsonist database; lack of
due diligence over ERP transition;
failure to timely implement statutory
changes; failure to comply with the
Illinois Fire Prevention Act; and
inadequate interagency agreement with
the Department of Innovation and
Technology.  We will review the
Office’s progress towards the
implementation of our recommendations
in our next compliance examination.

ACCOUNTANT’S OPINION

The accountants conducted a compliance
examination of the Office for the two
years ended June 30, 2020, as required
by the Illinois State Auditing Act.
Because of the effect of the
noncompliance described in Findings
2020-001 through 2020-016, the
accountants stated the Office did not
materially comply with the specified
requirements described in the report.

This compliance examination was
conducted by the Office of the Auditor
General’s staff.

JANE CLARK
Division Director

This report is transmitted in
accordance with Section 3-14 of the
Illinois State Auditing Act.

FRANK J. MAUTINO
Auditor General

FJM:JMR