OFFICE OF THE CONTROLLER CITY AND COUNTY OF SAN FRANCISCO Ben Rosenfield Controller Todd Rydstrom Deputy Controller MEMORANDUM TO: Naomi M. Kelly, City Administrator Office of the City Administrator FROM: Mark de la Rosa, Acting Director of Audits Audits Division, City Services Auditor DATE: October 22, 2020 SUBJECT: The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence EXECUTIVE SUMMARY The Office of the Controller’s City Services Auditor (CSA) assessed whether all the pharmaceutical (drug) evidence, which includes prescription and illicit drugs, that should be present is present, properly sealed in bags, securely stored, and logged by the Office of the Chief Medical Examiner (OCME). The assessment found that virtually all (99.9 percent) of the drug evidence that was included in the log is present at OCME’s office and almost all of it is properly sealed in bags. However, of the 1,738 bags of drug evidence we tested, 2 are missing and 10 are unsealed. Further, OCME documentation is insufficient to determine a complete inventory of the drug evidence stored, and departmental policies are inadequate to ensure the proper handling, tracking, and documenting of drug evidence. BACKGROUND, OBJECTIVE & METHODOLOGY Background CSA conducted this assessment at the Office of the City Administrator’s request. Office of the Chief Medical Examiner OCME provides forensic death investigation services for the public and the agencies of the City and County of San Francisco (City). OCME investigates sudden, unexpected, or violent deaths. OCME’s Forensic Laboratory Division is the testing center for postmortem specimens from cases investigated by OCME and does human performance testing in living persons, such as tests related to public intoxication, driving under the influence, and drug-facilitated sexual assaults. CITY HALL • 1 DR. CARLTON B. GOODLETT PLACE • ROOM 316 • SAN FRANCISCO, CA 94102-4694 PHONE 415-554-7500 • FAX 415-554-7466 2 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Inventory Drug evidence includes prescription pharmaceuticals, illicit drugs, and drug paraphernalia. OCME investigators are to collect drug evidence at death scenes and bring it back to the office. According to OCME staff this evidence may be found in the possession of or near a deceased person. When the evidence first arrives at the office, it is sorted in a room on the first floor. Once evidence is sorted, staff is to place drug evidence in sealed evidence bags and label each with a case number. Staff is then supposed to log information about any drug evidence into the case management system. Once drug evidence is bagged and labeled, investigators are to place it in evidence lockers outside of the evidence room and indicate in the handwritten Laboratory’s Pharmaceutical Evidence Logbook (drug evidence log or simply log) that this has occurred. Evidence bags are to be stored in boxes labeled by case number. According to the department’s Pharmaceutical Evidence Receipt, Storage, and Disposal Policy (policy), two employees should review the drug evidence log weekly and store in boxes any drug evidence bags that have not yet been stored. The responsible employee is to indicate storage completion by noting their initials in the log. Departmental policy also requires the Forensic Laboratory Division to maintain all drug evidence for at least one year from the date of receipt and then send it for disposal. The policy provides specific instructions for drug evidence disposal, including that two employees in different job classifications must sort evidence and identify the items that should be disposed of (because they are no longer needed). A city vendor is then to professionally remove and dispose of the drug evidence. After the vendor collects the evidence for disposal, the policy requires staff to note in the log the evidence disposed of and date of disposal. Objective, Scope, and Methodology The objective of this assessment is to determine whether all the drug evidence, including prescription and illicit drugs, that should be present is present, properly sealed in bags, securely stored, and accounted for in the drug evidence log. The assessment also considered whether drug evidence that OCME should have destroyed was still in storage. The assessment considered all evidence stored and logged as having been received during January 1, 2016, through September 13, 2020. To achieve the objective, we:        Reviewed policy and procedures related to the receipt, storage, and disposal of drug evidence. Reviewed OCME’s drug evidence log for January 1, 2016, through September 13, 2020. Visited the facility where drug evidence is stored. Observed in-person all evidence stored in the high-density storage area. Tested OCME’s drug evidence log for January 1, 2016, through September 13, 2020, to determine whether all drug evidence listed in the log that should be present is present, is properly sealed in bags, and is securely stored. Tested that all drug evidence in storage is accounted for in the log. Documented the results of the fieldwork. 3 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence We could not determine—and, thus, will not attest to—what is in the evidence bags we observed. The assessment only determined the presence or absence of those evidence bags that OCME logged as containing prescription or illicit drugs. We did not break evidence seals or open evidence bags and did not quantify the contents of evidence bags. This assessment is a nonaudit service. Generally accepted government auditing standards do not cover nonaudit services, which are defined as professional services other than audits or attestation engagements. Therefore, OCME is responsible for the substantive outcomes of the work performed during this assessment and is responsible to be in a position, in fact and appearance, to make an informed judgment on the results of the nonaudit service. RESULTS Finding 1: Of 1,738 bags of drug evidence tested, 2 are unaccounted for and the seals on 10 are missing or compromised. We tested 1,738 drug evidence entries in OCME’s log and found that:    Two drug evidence bags, both of which appear to have contained illicit substances, are missing from inventory. The seals on 10 drug evidence bags were either missing or compromised, indicating that some or all of the drugs that were in these bags were removed or may have been removed. One unsealed bag was empty. In some instances, seals on drug evidence bags were not initialed or dated, which decreases the value of using seals as a control to prevent or detect evidence being stolen or tampered with. We also found that the department has inadequate internal controls to manage its drug evidence and department policy does not require regular review of its drug evidence inventory. Two evidence bags that appear to have contained illicit drugs are missing from inventory. Two (0.12 percent) of 1,738 drug evidence bags identified in OCME’s log are missing from the inventory we reviewed. According to the log and case management system, both evidence bags appear to have contained illicit drugs. One contained a “plastic baggie w/ Crystal substance” and the other a “bindle w/ crystalline substance.” We did not find an additional 3 evidence bags. Of these, the department stated that 2 were in refrigerated storage, which we did not search, and the other had been sent to the San Francisco Police Department. The log does not document that any evidence is in refrigerated storage or was released to an outside agency. According to the International Association for Property and Evidence, Inc., (IAPE), when drug evidence is moved, there should be documentation noting that the evidence has been checked out and by whom. Ideally, such documentation should also include when (date and time) and why the evidence was removed. Exhibit 1 summarizes the number of drug evidence log entries we tested and how many corresponding drug evidence bags we found. 4 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Exhibit 1: Of the 1,738 drug evidence bags logged as being on site as of September 20, 2020, 2 are missing and 3 are reported as located elsewhere. Description of Evidence Bags Tested Amount 1,733 In Refrigerated Storage, per OCME 2 Sent to an Outside Agency, per OCME 1 Not Found in Inventory 2 Total 1,738 Source: CSA review of OCME drug inventory; OCME drug inventory log According to an article published by the National Institutes of Health, proper documentation of a chain of custody is required for evidence to be admissible in legal proceedings, including in court. 1 Without such documentation, drug evidence may be inadmissible. According to OCME staff, all stored evidence containers should include all items indicated in the log. During the site visit we conducted at OCME to assess its drug evidence logging and storage process, department staff noted that drug evidence is kept only in the evidence room. Ten drug evidence bags were unsealed or had seals that were compromised. Of the 1,738 drug evidence bags reviewed, 10 (0.6%) were unsealed or their seals were compromised. Of the 10 bags, 1 was empty. According to the department’s log, the empty bag appears to have contained illicit substances. Further, we observed that seals on some of the uncompromised drug evidence bags were not properly initialed or dated by an OCME employee. According to department staff, each bag must be sealed and each seal must be initialed by the sealer. It is impossible to verify that nothing is missing from an evidence bag when it is unsealed or when its seal is compromised because OCME does not routinely record the quantities of each bag’s original contents. An unsealed drug evidence bag, a bag with a compromised seal, or a seal with no indication of who placed it on the bag leaves a missing link in the chain of custody. Exhibit 2 shows examples of a properly sealed drug evidence bag and an unsealed drug evidence bag that we observed at OCME. 1 A. Badiye, N. Kapoor, and R.G Menezes, "Chain of Custody (Chain of Evidence);" National Library of Medicine, National Institutes of Health, Last update 9/2/2020. 5 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Exhibit 2: Examples of a properly sealed evidence bag and an unsealed evidence bag Properly Sealed Evidence Bag Unsealed Evidence Bag The bag is sealed with “EVIDENCE” sticker over opening; seal is initialed and dated. Neither the bag (right) nor box that was inside it (left) are sealed, initialed, or dated. The box was found closed and within the bag. Source: Photo of unsealed evidence bag taken by CSA on 9/20/20 and photo of properly sealed evidence bag taken by OCME on 10/16/20. The IAPE, California Department of Justice, and California Commission on Peace Officer Standards and Training state that evidence containers should be completely sealed and the seals should be initialed and dated by the sealer. And, as stated above, for evidence to be used in legal proceedings, the chain of custody must be properly documented. The OCME policies we reviewed do not describe how to properly seal drug evidence, whether employees who seal evidence containers must initial and date the seals, or what to do if evidence bags must be opened and resealed. Finding 2: OCME’s documentation is insufficient to determine the complete inventory and contents of the department’s drug evidence. The department’s drug evidence log is not sufficiently accurate or detailed to properly account for all drug evidence. Without a full and accurate description of the contents of each evidence bag, OCME cannot determine that all the drugs that were received, bagged, and stored are still present days, months, or years later. The drug evidence log includes items that are not drugs or drug-related, drug evidence is insufficiently described, and at least one piece of drug evidence was logged but not received. Although some entries of non-drug evidence were appropriately canceled (crossed out) in the log, seven such items are listed in the log for the period tested. These items include a gunshot residue kit, handcuffs, and blood evidence. There is no indication in the log, such as a supervisor’s note, that these items should not have been entered there. For legal and inventory purposes, OCME investigators should sufficiently describe all drug and drug-related evidence in the log and exclude 6 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence evidence unrelated to drugs. However, this has not occurred—and evidence is insufficiently described—because the department does not appropriately oversee the log. Also, because entries in the log are handwritten, OCME misses the opportunity to use a digital intake procedure that could ensure the log only includes drug evidence. Further, the department lacks a policy to instruct investigators on how to handle items that have been listed in the incorrect log. 2 We found that one drug evidence item (noted on the log as “RX”) was logged, but apparently not received or stored. According to OCME, the evidence item was never stored in an evidence box. Whether this evidence was lost, stolen, or simply erroneously recorded is unclear. OCME policy dictates that the department should investigate any evidence that is logged but not received into storage. According to department management, it has no record of this case having been investigated and cited this as an area for improvement in the future. Few drug evidence log entries adequately describe the evidence bag’s contents; specific quantities, such as numbers of pills or weights of substances, are almost never stated. For example, many log entries describe the evidence as “1 Rx” or similar, making it unclear if this is one bottle of prescription medication, one pill, or something else. Other log entries simply describe the evidence as "drugs" with no amount or weight stated. 3 OCME requires its investigators to document in the appropriate log all drug or drug-related evidence brought to the office, but policy does not specify what information must be included in descriptions of the evidence logged. Without descriptions that include specific quantities, such as amounts or weights, OCME cannot determine whether all of the drugs that were logged are still in the corresponding evidence bags. Some log entries do not indicate the presence of drugs or unknown substances in the evidence description. For example, some log entries describe the evidence only as "drug paraphernalia," but we found the corresponding evidence bag held baggies of white powder. Further, one of the two evidence bags identified as unaccounted for in Finding 1 has the description of “drug para” (drug paraphernalia) in the log, but OCME’s case management system lists its contents as “plastic baggie w/ Crystal substance.” Although the case management system has more detailed descriptions of the contents of some evidence bags than does the drug evidence log, according to OCME, no comparison is done between the log and the case management system. As stated above, departmental policy requires OCME investigators to document all drug or drug-related evidence brought to the office. However, departmental policy neither specifies the information that must be included in the log’s evidence bag descriptions nor requires Forensic Laboratory Division staff to reconcile descriptions in the log with the case management system. Without an accurate description of an evidence bag’s contents or a comparison of the description in the log to that in the case management system, OCME cannot determine whether all of the drugs logged are still in the corresponding evidence bag. 2 We cannot determine whether non-drug evidence has been logged and stored appropriately because our assessment was limited to drug evidence. 3 This also raises the question of what types of drugs are present and how OCME staff determined the evidence is a drug. 7 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Finding 3: OCME’s drug evidence retention policies and procedures are inadequate and not always followed. One drug evidence bag has been held for more than 20 years. OCME has stored some drug evidence for many years—for more than two decades in at least one instance—based on outside requests regarding legal cases. OCME has not attempted to determine whether it can destroy the oldest evidence we found and lacks appropriate policies and procedures to document, handle, or decide when it can destroy such evidence. Exhibit 3: Drug evidence containers in a box dedicated to outside requests for retention are not properly sealed. OCME has some very old drug evidence. While looking for evidence bags corresponding to entries in the drug evidence log, we observed a box of drug evidence, shown in Exhibit 3, containing items with case numbers that did not correspond to any entries in the drug evidence log for the assessment period with the exception of one case. The box contains at least seven evidence bags that are not sealed or have seals that are broken. According to OCME, all evidence with case numbers preceding 2016-0914 (a number assigned approximately four years ago) were destroyed. However, this box contains evidence with case numbers predating the destruction cutoff, with some items from as long ago as 1999. OCME stated that it had kept this evidence because outside stakeholders, such as courts or law enforcement agencies, had requested that it not be destroyed. When we asked, OCME could not provide documentation to justify all the evidence that it has been asked not to destroy or even Source: CSA photo taken on 9/20/20 documentation to justify its retention of the evidence in the box pictured in Exhibit 3. According to OCME, the pre-2017 documentation of requests for extended retention is unclear. 4 Management also stated that, after its move to 1 Newhall Street (in 2017), the department stopped discarding evidence to ensure it was fulfilling previous requests for extended retention. OCME stated that it will include this box the next time it discards evidence after it contacts the relevant requestors and confirms that the evidence is no longer needed. Until such confirmation is obtained, according to OCME, extended retention items, such as those in the box, are not to be discarded. Some drug evidence may have been tested and the bags not resealed. Although OCME did not provide documentation to support this, it is possible that the drug evidence we observed in the box 4 Our assessment did not examine this documentation. 8 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence pictured in Exhibit 3 had to be tested, so the bags had to be opened. However, according to OCME, if this occurred, the original seal should not have been removed. Instead, management stated, bags should be opened in a way that does not compromise the original seal whenever possible. Per management, after the evidence needed for testing is removed, the bag should be immediately resealed, initialed, and placed back into inventory. Although these steps described are sound, they are not in the written policy or procedures OCME provided to us and were not followed in the case of the seven unsealed evidence bags we found. There is no indication in OCME policy or procedures of how staff is to document, handle, or track drug evidence that is retained indefinitely due to outside requests. OCME’s lack of systematic tracking (including inventorying), handling, and disposal of this evidence increases the risk that drug evidence is unaccounted for. When drug evidence is not strictly accounted for, this increases the opportunity for it to be mishandled, tampered with, lost, or stolen. The IAPE recommends that documentation should record all persons who have handled drug evidence and include storage locations and transaction dates and times. 5 OCME does not follow its policy on the storage and handling of “no-case” evidence. We observed a box that contains “no-case” evidence, which is drug evidence that OCME staff collects but that is later determined not to be within OCME’s jurisdiction. The case numbers on the containers indicate that the items in the box were logged from January 2016 through September 2019. According to OCME policy and procedures, the “no-case” boxes should be closed at the end of each calendar year, and a new box should be started at the beginning of a new year even if the last box is not full. The document also states that the drug evidence log should contain a separate section for “no cases.” However, we found “no-case” entries scattered throughout the log. 6 Because OCME has not followed either of these procedures, it is difficult to trace “no-case” evidence, increasing the likelihood that it could be lost or stolen. Finding 4: The department has not disposed of any drug evidence since 2017. OCME should strengthen its controls to ensure drug evidence is destroyed when no longer needed and stored securely as long as it is needed to decrease the risk that it could be tampered with, lost, or stolen. OCME has not disposed of any drug evidence since 2017. Departmental policy requires the Forensic Laboratory Division to maintain all drug evidence for at least one year from the date of receipt. This policy is unclear in terms of retention duration and is incomplete: it states that evidence should be kept for at least one year but does not state when evidence should be destroyed. The IAPE suggests that an organization’s policy should define a threshold for evidence destruction, based on either storage duration or evidence quantity, to ensure consistency in how a lab handles evidence and to promote accountability for the evidence a lab has or had in its custody. By infrequently arranging for 5 International Association for Property and Evidence, Inc., Professional Standards, 2016, p. 42. This conclusion is based on OCME’s statement that “no-case” evidence is typically denoted in the log with a case number beginning with NC or Pend @. We did not observe any other physical “no-case” evidence. 6 9 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence the destruction of unneeded evidence, OCME is retaining over 1,200 bags of drug evidence longer than required, which puts its drug evidence at greater risk of being tampered with, lost, or stolen. 7 The evidence storage room’s only security camera does not provide a view of the area where drug evidence is stored. The camera is aimed at the lockers where evidence handoffs are made, but most of OCME’s drug evidence is stored in shelves that are beyond the camera’s view. Further, OCME stated that no one regularly monitors the video from any of the security cameras in the lab area, including the camera in the evidence storage room. The IAPE and California Commission on Peace Officer Standards and Training recommend video monitoring of drug storage areas to record the activities there and in entry and exit areas connected to such areas. Because OCME’s drug evidence storage shelves are not in the security camera’s view, any employee with access to the room could tamper with or take drug evidence stored there without this being recorded. Recommendations The Office of the Chief Medical Examiner should: 1. Investigate all missing drug evidence and unsealed drug evidence identified in this assessment, including the evidence in the box dedicated to outside requests for retention described in this report. 2. Periodically inventory all drug evidence to ensure it is accounted for and in properly sealed bags or boxes. Immediately investigate any missing drug evidence or drug evidence containers with seals that are broken or otherwise compromised. 3. Revise its policy and procedures to require employees who seal drug evidence containers to write their initials and the date on each seal. A seal should be applied when the evidence is first packaged and whenever the container is unsealed and resealed. 4. Cease using a handwritten log for the intake of drug evidence. To ensure all drug evidence is accounted for, use the case management system or another electronic system for evidence intake. 5. Revise its policy and procedures to specify: a. That staff must note the entire contents of a drug evidence bag in the description field of the system of record that will succeed the handwritten log. b. The information that staff must include in the description field of a drug evidence bag’s contents when the bag is logged for storage. This information should be listed in detail and include, at a minimum, descriptions and quantities of each substance, such as the color of pills or tablets, any markings on them, the number of pills in a container, the number of containers, and the weights of loose substances such as crystals or powders. The procedure should note that descriptions such as “1 Rx” or “drugs” are insufficient. 7 Our assessment did not attempt to determine how many of OCME’s drug evidence items are unneeded and should be destroyed. 10 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence 6. Add to its policy and procedures to specify how drug evidence that will be retained indefinitely, including “no-case” evidence, should be documented, handled, stored, and eventually approved for destruction. 7. Revise its policy to mandate that drug evidence that is no longer needed be destroyed periodically—not less often than yearly—and create and follow a written procedure to arrange for the destruction of such evidence. 8. Consider adding one or more video security cameras in the evidence storage room. Whether or not a camera or cameras can be added there, at least one should have a view of the shelves where drug evidence is stored. Otherwise, add a compensating control, such as requiring that no employee be allowed in the evidence storage room alone; at least two must be present. 9. Create and follow a procedure that requires a supervisor to periodically—not less often than monthly—review video recorded in the evidence storage room to check for any irregularities in evidence handling that may be observed. 11 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence cc: City Administrator/OCME Naomi Kelly Ken Bukowski Jennifer Johnston Dr. Luke Rodda Controller Ben Rosenfield Todd Rydstrom Kate Chalk Todd Ojo Dave Jensen Eryl Karr Alice Duncan-Graves Matthew Thomas Elena Rein Board of Supervisors Budget Analyst Citizens Audit Review Board City Attorney Civil Grand Jury Mayor Public Library 12 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Attachment Department Response CITY HALL • 1 DR. CARLTON B. GOODLETT PLACE • ROOM 316 • SAN FRANCISCO, CA 94102-4694 PHONE 415-554-7500 • FAX 415-554-7466 13 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Recommendations and Responses For each recommendation, the responsible agency should indicate in the column labeled Agency Response whether it concurs, does not concur, or partially concurs and provide a brief explanation. If it concurs with the recommendation, it should indicate the expected implementation date and implementation plan. If the responsible agency does not concur or partially concurs, it should provide an explanation and an alternate plan of action to address the identified issue. Recommendation Agency Response CSA Use Only Status Determination* The Office of the Chief Medical Examiner should: 1. Investigate all missing drug evidence and unsealed drug evidence identified in this assessment, including the evidence in the box dedicated to outside requests for retention described in this report. 2. Periodically inventory all drug evidence to ensure it is accounted for and in properly sealed bags or boxes. Immediately investigate any missing drug evidence or drug evidence containers with seals that are broken or otherwise compromised. ☒ Concur ☐ Do Not Concur ☐ Partially Concur As of 10/06/20, the OCME has investigated all missing drug evidence and unsealed drug evidence identified in this assessment. All unsealed or improperly packaged items have been addressed. No records exist for the extended retention requests for the items described in this report and the items are slated for disposal. Disposal, following review of and solicitation of key stakeholders for extended evidence retention requests, will be scheduled to be completed by 12/31/20. ☒ Concur ☐ Do Not Concur ☐ Partially Concur The OCME has begun a revision of existing policy to include detailed evidence submission guidelines to more clearly define categories of evidence, selection of appropriate packaging, description of evidence submissions, documentation of submissions collected and submitted, and proper use of evidence seals. To minimize exposure of drug evidence to tampering or theft, the in-progress revision also includes contemporaneous sealing of storage boxes such that no more than one of each type of storage box is unsealed at any time. Monthly supervisory review and inventory of storage boxes will also be required. The first draft of the revised policy is targeted for 11/01/20 completion. CITY HALL • 1 DR. CARLTON B. GOODLETT PLACE • ROOM 316 • SAN FRANCISCO, CA 94102-4694 PHONE 415-554-7500 • FAX 415-554-7466 ☒ Open ☐ Closed ☐ Contested ☒ Open ☐ Closed ☐ Contested 14 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Recommendation Agency Response CSA Use Only Status Determination* The Office of the Chief Medical Examiner should: As part of OCME’s work on the final implementation stages of the electronic case management system, we will assess the system’s ability to facilitate evidence control, inventory management and disposal requirements of the department. 3. Revise its policy and procedures to require employees who seal drug evidence containers to write their initials and the date on each seal. A seal should be applied when the evidence is first packaged and whenever the container is unsealed and resealed. 4. Cease using a handwritten log for the intake of drug evidence. To ensure all drug evidence is accounted for, use the case management system or another electronic system for evidence intake. ☒ Concur ☐ Do Not Concur ☐ Partially Concur As described in #2, the first draft of the revised policies and procedures, including initial and subsequent packaging and sealing requirements, is targeted for 11/01/20 completion. ☒ Open ☐ Closed ☐ Contested The draft will also be updated to reflect recent existing practices requiring the appropriate documentation following retrieval, analysis of, and return of pharmaceutical evidence. ☒ Concur ☐ Do Not Concur ☐ Partially Concur Existing OCME policy requires two authorized staff members to access pharmaceutical evidence storage and to receive, retrieve or prepare for disposal of pharmaceutical evidence for each evidence submission. However, existing documentation only records one of the two individuals. Effective 10/09/20, the practice now requires documentation of both participating individuals. The in-progress policy revision will reflect this change in the first draft, targeted for 11/01/20 completion. In advance of final and full implementation of the electronic case management system, this revision improves evidence control. ☒ Open ☐ Closed ☐ Contested 15 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Recommendation Agency Response CSA Use Only Status Determination* The Office of the Chief Medical Examiner should: 5. Revise its policy and procedures to specify: a. That staff must note the entire contents of a drug evidence bag in the description field of the system of record that will succeed the handwritten log. b. The information that staff must include in the description field of a drug evidence bag’s contents when the bag is logged for storage. This information should be listed in detail and include, at a minimum, descriptions and quantities of each substance, such as the color of pills or tablets, any markings on them, the number of pills in a container, the number of containers, and the weights of loose substances such as crystals or powders. The procedure should note that descriptions such as “1 Rx” or “drugs” are insufficient. ☐ Concur ☐ Do Not Concur ☒ Partially Concur Contents of pharmaceutical evidence submissions are currently described in the OCME online case record. The narrow purpose of the pharmaceutical log is to facilitate the transfer and not to provide a full account of the contents. The OCME will create a list of abbreviations providing additional description as part of the drug evidence storage submission process to facilitate the transfer while the need for a transfer log persists. As discussed during this assessment process, even in the OCME case record, the number of pills and the weights of loose substances are not critical to the intent and purpose of pharmaceutical evidence submission in death investigation. Identifying the quantities of each substance, such as the color of pills or tablets, markings on them, the number of pills in a container, and the weights of loose substances such as crystals or powders may typically be standard procedure for a Police Crime Lab as a necessary part of criminal investigations but the drug evidence stored as part of the OCME death investigations does not require this detailed level of documentation. Pharmaceutical evidence in homicide cases is typically collected by Police at the scene and not by OCME Investigators. Nonetheless, the OCME will implement alternative strategies to streamline documentation of drug evidence bag contents. One example strategy is to require additional photo documentation of drug evidence prior to packaging and submission to visually represent the complete contents. The specific descriptors required for evidence ☒ Open ☐ Closed ☐ Contested 16 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Recommendation Agency Response CSA Use Only Status Determination* The Office of the Chief Medical Examiner should: collected, such that the item(s) can be visualized without physical examination, will be defined in OCME policy revisions. 6. Add to its policy and procedures to specify how drug evidence that will be retained indefinitely, including “no-case” evidence, should be documented, handled, stored, and eventually approved for destruction. ☒ Concur 7. Revise its policy to mandate that drug evidence that is no longer needed be destroyed periodically—not less often than yearly—and create and follow a written procedure to arrange for the destruction of such evidence. ☒ Concur 8. Consider adding one or more video security cameras in the evidence storage room. Whether or not a camera or cameras can be added there, at least one should have a view of the shelves where drug evidence is stored. Otherwise, add a compensating control, such as requiring that no employee be allowed in the evidence storage room alone; at least two must be present. ☒ Concur ☐ Do Not Concur ☐ Partially Concur As mentioned in #2, the first draft of revised policies and procedures is targeted for 11/01/20 completion and will include procedures for the documentation, handling, storage and destruction of extended evidence retention requests procedure, including “no-case” pharmaceutical evidence. ☐ Do Not Concur ☐ Partially Concur As mentioned in #2, the first draft of revised policies and procedures is targeted for 11/01/20 completion and will include a defined time threshold of not less often than yearly. Further, a disposal event, following review of and solicitation of key stakeholders for extended evidence retention requests, will be planned by 12/31/20. ☐ Do Not Concur ☐ Partially Concur Cameras already exist to capture the entry and exit of the evidence storage room. Further, this room has particularly limited access, only available to necessary job classifications. The OCME will consider the effectiveness of additional cameras, which will also require a budget request to pay for additional cameras. Existing internal policy requires two authorized staff members to access pharmaceutical evidence storage and to receive, retrieve or prepare for disposal pharmaceutical evidence for each evidence submission. However, the storage room contains other non- ☒ Open ☐ Closed ☐ Contested ☒ Open ☐ Closed ☐ Contested ☒ Open ☐ Closed ☐ Contested 17 The Office of the Chief Medical Examiner Must Improve Inventory Management to More Effectively Safeguard and Track Its Drug Evidence Recommendation Agency Response CSA Use Only Status Determination* The Office of the Chief Medical Examiner should: pharmaceutical evidence. While the suggested compensating control may be effective, the effectiveness is limited to compliance with such a policy, consistent with current practices. 9. Create and follow a procedure that requires a supervisor to periodically—not less often than monthly—review video recorded in the evidence storage room to check for any irregularities in evidence handling that may be observed. ☐ Concur ☐ Do Not Concur ☒ Partially Concur As described in #2, the contemporaneous sealing of storage boxes and required monthly supervisory review of storage boxes are among the revisions planned. By requiring submissions to be sealed prior to receipt, sealing boxes as they are filled, periodically reviewing storage boxes, and regularly discarding drug evidence beyond retention, OCME strengthens the existing procedures and increases the controls for tracking and safeguarding pharmaceutical evidence. We will consider a regular review of video footage, but it is believed that these other strategies will be more effective than a monthly review of all video footage for the room. Video footage will be reviewed should an irregularity be identified through the monthly review of storage boxes conducted by supervisors. ☒ Open ☐ Closed ☐ Contested