oversight

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)

     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
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