United States Department of Agriculture FSIS Final Action Verification—Audit of Food Safety and Inspection Service Ground Turkey Inspection and Safety Protocols Report 24026-0002-22 February 2020 OFFICE OF INSPECTOR GENERAL United States Department of Agriculture Office of Inspector General Washington, D.C. 20250 DATE: February 24, 2020 FAV NUMBER: 24026-0002-22 TO: Stanley McMichael Associate Chief Financial Officer Office of the Chief Financial Officer FROM: Gil H. Harden Assistant Inspector General for Audit SUBJECT: FSIS Final Action Verification—Audit of Food Safety and Inspection Service Ground Turkey Inspection and Safety Protocols The Office of Inspector General (OIG) completed a final action verification of all eight recommendations in our July 2015 report on the Audit 24601-0004-31, Food Safety and Inspection Service Ground Turkey Inspection and Safety Protocols. Final action verification (FAV) determines whether the final action documentation the agency provides to the Office of the Chief Financial Officer (OCFO) supports the agency’s management decision reached with OIG. 1, 2 Our objective was to determine whether the documentation the Food Safety Inspection Service (FSIS) provided to OCFO was sufficient to close the recommendations made in Audit Report 24601-0004-31. In a memorandum dated July 5, 2018, OCFO reported to FSIS that final action was complete for all recommendations in the subject audit report. Based on our review of the documentation in OCFO’s files, we concur with this decision for Recommendations 1, 2, 3, 4, 5, 7, and 8. Table 1 summarizes the actions FSIS took with respect to these recommendations. However, we do not concur with this decision for Recommendation 6. Table 2 provides information on Recommendation 6, including the reasons why the documentation provided was not sufficient to close the recommendation. 1 Final action is the completion of all actions that management has concluded, in its management decision, are necessary with respect to the finding and recommendations included in an audit report. DR1720-001, 6g(1), Audit Follow-up and Management Decision (Nov 2, 2011). 2 Management decision is an agreement between agency management and OIG on the action(s) taken or to be taken to address a finding and recommendations cited in an audit report. The management decision must include the agreed-upon dollar amount affecting the recommendations and an estimated completion date unless all corrective action is completed by the time agreement is reached. DR1720-001, 6i, Audit Follow-up and Management Decision (Nov 2, 2011). Stanley McMichael 2 As noted in its response, OCFO agreed to reopen Recommendation 6 in its Audit Follow-up Tracking and Reporting (AFTR) system. OCFO stated that, subsequent to reopening the recommendation, an official memorandum will be prepared and sent to FSIS. The memorandum will explain that Recommendation 6 has been reopened and will remain open until OCFO receives evidence to support final action or explanation for not implementing actions as agreed in the management decision. In addition, the memorandum to FSIS will convey OCFO's intention to conduct periodic follow-up meetings to track FSIS' progress in implementing this recommendation. Background Our report, FSIS Ground Turkey Inspection and Safety Protocols, made eight recommendations to FSIS.3 OIG reviewed FSIS’ inspection of ground turkey, including sampling and testing protocols, to evaluate the effectiveness of the ground turkey and other turkey products safety programs. OIG determined that FSIS could improve how it monitors the safety of turkey products. OIG and FSIS reached management decision on all eight of the recommendations in a memorandum dated August 3, 2015. The memorandum detailed what actions FSIS needed to implement in order to achieve final action on the recommendations. In accordance with Departmental Regulation 1720-001, the OCFO has the responsibility to determine final action for recommendations where OIG has agreed to management decision.4 As such, OCFO evaluates agency-provided documentation to support planned corrective actions and to determine if final action has occurred. Scope and Methodology The scope of this FAV is limited to determining whether FSIS' plan of action for all of the recommendations in the original audit report were completed in accordance with the management decisions reached on August 3, 2015. To accomplish our objective, we reviewed documentation FSIS submitted to the OCFO. We did not perform internal control testing or make site visits to determine whether the underlying deficiencies that were initially identified had been corrected. In addition, we did not provide an opinion on the results of the implementation or effectiveness of each recommendation. This FAV was conducted in accordance with our internal guidance IG-7710, Nonaudit Work and Final Action Verification Guidance and Procedures. As a result, this FAV is not conducted in accordance with Generally Accepted Government Auditing Standards, issued by the Comptroller General of the United States, or the Quality Standards for Inspection and Evaluation, issued by the Council of the Inspectors General for Integrity and Efficiency. However, before we performed the non-audit service, we determined that it would not impair our independence to perform audits, inspections, attestation engagements, or any other future or ongoing reviews of the subject. 3 Audit Report 24601-0004-31, FSIS Ground Turkey Inspection and Safety Protocols, dated July 29, 2015. 4 DR1720-001, 7d(1-9), Audit Follow-up and Management Decision (Nov 2, 2011). Stanley McMichael 3 Results of Final Action Verification Recommendations with Sufficient Documentation We determined that FSIS provided sufficient documentation to OCFO of corrective actions implemented to achieve final action for seven recommendations in the subject report (Recommendations 1, 2, 3, 4, 5, 7, and 8). We detail the reasons for our determinations in Table 1. Table 1. Recommendations with Sufficient Documentation to Achieve Final Action Rec. No. Recommendation Action Taken 1 For future Salmonella Initiative FSIS has developed sample letters that it Program (SIP) letters, if the agency plans to use in the future when an elects to issue new SIP waivers, at the establishment requests a waiver from regulatory requirements under a SIP approval process, develop one waiver. These sample letters serve to consolidated document including document that FSIS has implemented appropriate attachments that clearly the new process for SIP letters. FSIS and concisely outlines the waived will send one consolidated revised SIP procedures, the plant’s requirements waiver letter that includes attachments based on the waiver, and supporting that outline the waived procedures, and documents the plant will make the procedures the plant is required to follow based on the waiver. The revised available so that the Inspection SIP letter will also instruct that the Program Personnel (IPP) can fully and establishment must provide supporting adequately monitor the plant’s records and documents to IPP for compliance with the SIP letter. verification purposes. The revised SIP letter also outlines the IPP establishment verification responsibilities. 2 To determine compliance with SIP FSIS has performed public health risk letters and IPP monitoring of the SIP evaluations (PHRE) on a random letter, perform a review of plants with sample of 16 out of the 22 young chicken and young turkey SIP letters using similar tools to those establishments with SIP line speed which Enforcement Investigation and waivers. This review identified that (1) Analysis Officers (EIAO) use in their plants are following the SIP protocol, verification of SIP procedures while (2) IPP adequately monitor SIP, (3) performing Food Safety Assessments EIAOs were aware the establishments (FSA). were participating in SIP, and (4) IPP were documenting SIP-specific information through either the Memorandum of Interview (MOI) or in direct communication with the EIAO. Stanley McMichael 4 Rec. No. Recommendation Action Taken 3 Based on the results of FSIS’ review of FSIS has revised Directive 5020.1, Verification Activities for the use of New plants with SIP letters, take appropriate actions to modify procedures for Technology in Meat and Poultry Establishments and Egg Products monitoring compliance with existing Plants dated October 6, 2016, to provide SIP letters and all future SIP letters. IPP with additional instructions on monitoring compliance with all existing and future SIP letters. This directive cancels Directive 5020.1, Verification of Salmonella Initiative Program. 4 Review the process of how sanitation FSIS has developed and performed an Noncompliance Records (NRs) are analysis, FSIS Ground Turkey drafted and the data that are recorded, Inspection and Safety Protocols: in order to develop a methodology to Poultry Sanitary Dressing assure the information recorded in them Noncompliance Analysis dated February can be better utilized by the agency to 2017. In the analysis FSIS considered determine the scope and complexity of whether the utilization of sanitation any underlying plant process control noncompliance records could be issues. Based on the review, FSIS improved and better inform PHRE and should develop a plan with appropriate FSA scheduling. From this review FSIS timeframes and milestones to recommended that Sanitary Dressing implement the new and improved NRs should not be weighted differently methodology. than other types of NRs when deciding to change its operations. This analysis also suggests that IPP have a greater understanding of the Sanitary Dressing Task and how to document noncompliance, and that FSIS’ efforts to clarify documentation of sanitation NRs have had a positive impact. 5 Establish a formal system to FSIS has developed a chart that includes periodically review and update agency all current FSIS Directives in the 1,000- directives to assure that they are still 13,000 series. This chart is reviewed applicable and technically accurate. and updated quarterly by FSIS program areas to determine whether the directives are up-to-date, or whether they need to be revised or canceled. As a result of instituting this process, FSIS has identified a number of directives that FSIS plans to revise or cancel over Stanley McMichael 5 Rec. No. Recommendation Action Taken the next year. FSIS has completed establishing a formal system to periodically review and update Agency directives. 7 Develop a plan with appropriate FSIS has developed the fourth edition of timeframes and milestones to issue the Compliance Guideline for appropriate guidance to establishments Controlling Salmonella and Campylobacter in Raw Poultry dated on how to improve their turkey December 2015 to assist poultry prerequisite programs in order to processors in controlling Salmonella correct the specific concerns addressed and Campylobacter in raw poultry in this finding. products. This guidance includes specific information to assist industry in properly addressing food safety concerns in the following seven areas: 1. recommended best practices, 2. information on the components of a prerequisite program, 3. recommendations for maintaining sanitary conditions during operations, 4. information explaining that sampling procedures should be described in a written program, 5. information explaining that interventions used (and their operational parameters) need to be safe and suitable, 6. information on how establishments should document their use of antimicrobial interventions, 7. information on actions that establishments should take if they find steps in their prerequisite programs have not been properly implemented or followed. Stanley McMichael 6 Rec. No. Recommendation Action Taken 8 Review the Hazard Analysis FSIS has developed Analysis of Verification (HAV) Directive, as Prerequisite Program Noncompliance related to the issues from this finding. Records Issued During HAV Tasks, dated December 12, 2016. In this Determine if the concerns raised in our analysis, FSIS evaluated how IPPs are report should be incorporated into FSIS accessing establishments’ prerequisite procedures for field personnel when programs during the performance of the they perform a HAV task. If HAV task and determined that IPP need warranted, develop a plan with additional direction. FSIS Directive appropriate timeframes and milestones 5000.6, Performance of The Hazard to provide additional guidance to the Analysis Verification Task, needed to be revised to include additional FSIS IPP or revise and reissue the FSIS instructions. HAV Directive. Recommendatoin without Sufficient Documentation FSIS did not take proper corrective action and did not provide sufficient documentation to OCFO for Recommendation 6. Although OCFO closed the recommendation, we do not concur that the corrective action implemented achieved final action for this recommendation. We detail the reason for our determination in Table 2. We informed FSIS officials of the results of this final action verification on September 27, 2019. Table 2. FSIS’ Implemented Corrective Action Insufficient to Achieve Final Action Rec. Recommendation Action Taken Reason Not No. Sufficient to Close 6 Develop a plan with FSIS had made public the FSIS did not develop a appropriate timeframes prevalence estimate for schedule, with and milestones to revise comminuted poultry products, milestones, for prevalence estimates for turkey the agency’s pathogen periodically updating and broiler carcasses and sampling program in order chicken parts at Sampling Salmonella prevalence to consider the following Results for FSIS Regulated estimates. issues: Products: https://www.fsis.usd a.gov/wps/portal/fsis/topics/dat (1) sampling of a-collection-and- imports, reports/microbiology/sampling (2) sampling of -project-results/results. currently exempt However, FSIS also agreed to plants, develop a schedule, with milestones, for periodically Stanley McMichael 7 Rec. Recommendation Action Taken Reason Not No. Sufficient to Close (3) sampling of updating Salmonella Category 1 plants, prevalence estimates. and (4) sampling to determine the estimated prevalence of Salmonella. OCFO should reopen Recommendation 6 and obtain the correct documentation to support final action from FSIS. We request that you provide us verification that corrective action was taken to sufficiently achieve final action for this recommendation. As noted in its response, OCFO agreed to reopen Recommendation 6 in its AFTR system. Subsequent to reopening the recommendation in AFTR, an official memorandum will be prepared and sent to FSIS. The memorandum will explain that Recommendation 6 has been reopened and will remain open until OCFO receives evidence to support final action or explanation for not implementing actions as agreed in the management decision. In addition, the memorandum to FSIS will convey OCFO's intention to conduct periodic follow-up meetings to track FSIS' progress in implementing this recommendation. The memorandum to FSIS and the reopening of Recommendation 6 will be completed by January 31, 2020. cc: Cara LeConte, Chief Financial Officer, Food Safety and Inspection Service United States January 22, 2020 Department of Agriculture Office of the Chief Financial Officer TO: Gil H. Harden Assistant Inspector General for Audit 1400 Independence Office of the Inspector General Avenue, SW Washington, DC FROM: Stanley McMichael /s / 20250 Associate Chief Financial Officer SUBJECT: Food Safety and Inspection Service—Final Action Verification—FSIS Ground Turkey Inspection and Safety Protocols—24601-0004-31 We have reviewed the Office of Inspector General (OIG) memorandum dated December 23, 2019 on the subject audit. In response to the draft report, the Office of the Chief Financial Officer (OCFO) will reopen Recommendation 6 in our “Audit Follow-up Tracking and Reporting” system (AFTR), upon receipt of the final (OIG) report. Subsequent to reopening the recommendations in AFTR, an official memorandum will be prepared and sent to the Food Safety and Inspection Service’s (FSIS) Chief Financial Officer. The memorandum will explain why Recommendation 6 has been reopened and will remain open until OCFO receives evidence to support final action or explanation for not implementing actions as agreed in the management decision. In addition, the memorandum to FSIS will convey OCFO’s intention to conduct periodic follow-up meetings to track FSIS’ progress in implementing this recommendation. The memorandum to FSIS and the reopening of Recommendation 6 will be completed by January 31, 2020. If you have any questions or need additional information, please have a member of your staff contact Annie Walker, Director, Internal Control Division at (202) 720-9983. Attachment FSIS—Final Action Verification— FSIS Ground Turkey Inspection and Safety Protocols—24601-0004-31 Management Response Recommendation 6: Upon receipt of OIG’s final action verification report, OCFO will reopen recommendation 6. OCFO will prepare an official memorandum addressed to the FSIS’ Chief Financial Officer requesting the agency provide evidence demonstrating that it has developed a schedule, with milestones, to periodically update Salmonella prevalence estimates. Corrective Action completion date: January 31, 2020 Responsible Organization: OCFO Internal Control Division Learn more about USDA OIG Visit our website: www.usda.gov/oig Follow us on Twitter: @OIGUSDA Report Suspected Wrongdoing in USDA Programs OIG Hotline: www.usda.gov/oig/hotline.htm Local / Washington, D.C. (202) 690-1622 Outside D.C. 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FSIS Final Action Verification - Audit of Food Safety and Inspection Service Ground Turkey Inspection and Safety Protocols
Published by the Department of Agriculture, Office of Inspector General on 2020-02-28.
Below is a raw (and likely hideous) rendition of the original report. (PDF)