oi g 13029 final report

BROWARD OFFICE OF THE INSPECTOR GENERAL

Honorable Barbara Sharief, Mayor, Broward County and Members, Broward Board of County Commissioners

MEMORANDUM

To:

From: John W. Scott, Inspector General

Date: May 7, 2014

Subject: OIG Final Report Re: Misconduct and Gross Mismanagement by the Broward County Animal Care and Adoption Division, Ref. OIG 13-029

Attached please find the final report of the Broward Office of the Inspector General (OIG) regarding the above-captioned matter. The OIG investigation found that the Broward County Animal Care and Adoption Division (ACAD) engaged in repeated instances of misconduct and gross mismanagement that violated the law, including:

Mishandling controlled substances, intended for euthanizing animals but also known to

be abused by humans as date rape drugs, by failing to secure them properly;

Failing to take reasonable precautions against the misuse, theft, loss, or diversion of the drugs;

Failing to administer rabies vaccinations to animals prior to their return to owners,

including multiple instances where the animals had a known history of biting people,

despite the fact that county law unequivocally requires that the vaccinations be made;

Permitting unauthorized personnel to administer rabies vaccine in violation of Florida law;

Allowing its state and federally mandated permit and registration to lapse;

Repeatedly, and again in violation of county law, waiving impound and boarding fees and deciding not to issue citations at the shelter for unregistered, unvaccinated or at-large animals returned to their owners; and

John W. Scott, Inspector General One North University Drive, Suite 111 Plantation, Florida 33324 (954) 357-7873 Fax (954) 357-7857

www.browardig.org (954) 357-TIPS

www.hnlwardi

Failing to track waivers and establish standardized criteria for them, resulting in the inability to assess the fiscal impact on animal care funding.

ACADs failure to operate responsibly in this regard has recklessly created a public health and safety risk for all Broward residents and visitors. This report contains recommendations intended to rectify ACADs management deficiencies and ensure compliance with local, state and federal controlled substance standards.

ACAD has recently requested the drafting of an ordinance that will, in part, permit ACAD to continue practices that were previously barred by law.1 ACADs motion did not inform the County Commission that for at least two years, it had already been engaging in the very same activities for which it is now requesting authority. The motion also failed to address the deficiencies in ACADs current activities, such as a lack of criteria or documentation for the fees and fines waived by the department. Similarly, in connection with the proposed ordinance, the Office of Management and Budget observed in a fiscal impact statement that [d]ue to the recent focus by the Division on quickly reuniting pet owners with their pets in hopes of establishing positive outcomes, similar practices were recently put into place and the proposed ordinance is not expected to have any additional fiscal impact. (Emphasis added). The motion and the statement both misrepresent the duration of ACADs actions, and make no attempt to apprise this Commission, and the public, of the undeniably negative fiscal impact on animal care funding those actions have already had. Such a lack of transparency is a disservice to both the County Commission and Broward residents.

The OIG takes no position on a policy decision to implement a fee waiver or delayed citation program. But those policy decisions should be made by the informed vote of Browards elected officials, after careful evaluation of their fiscal impact. Accordingly, we recommend that if it is determined that such programs serve a desired public purpose, they should be structured to transparently track fiscal impact, avoid arbitrary application, and avoid gross mismanagement.

Attachment

1 The ordinance change is currently scheduled for a public hearing on May 13, 2014.

BROWARD OIG PAGE 2 OF 2

BROWARD OFFICE

OF THE INSPECTOR GENERAL

FINAL REPORT

===========================================================

OIG 13-029 May 7, 2014

Misconduct and Gross Mismanagement by the Broward County Animal Care and Adoption Division


FINAL REPORT RE: MISCONDUCT AND GROSS MISMANAGEMENT BY THE BROWARD COUNTY ANIMAL CARE AND ADOPTION DIVISION

TABLE OF CONTENTS

Summary.............................................................................................................................................. 1 OIG Charter Authority......................................................................................................................... 3 Entities and Individuals Covered in this Report .................................................................................. 3 Relevant Governing and Administrative Authorities .......................................................................... 5 Investigation ........................................................................................................................................ 7

Mishandling of Controlled Substances ............................................................................................. 8 Failure to Monitor, Control and Properly Administer Use of Controlled Substances.................... 11 Failure to Administer Rabies Vaccinations .................................................................................... 14 Failure to Collect Required Fees and Charges and to Issue and Enforce At-large Citations ......... 16

Interview Summaries Specialist A ..................................................................................................................................... 20 Specialist B ..................................................................................................................................... 20 Specialist C ..................................................................................................................................... 23 Specialist D ..................................................................................................................................... 25 Specialist E ..................................................................................................................................... 26 Specialist F...................................................................................................................................... 27 Specialist G ..................................................................................................................................... 27 Specialist H ..................................................................................................................................... 28 Specialist I ...................................................................................................................................... 30 Specialist J ...................................................................................................................................... 30 Senior Specialist ............................................................................................................................. 31 Lead Veterinarian Technician......................................................................................................... 33 Customer Service Specialist ........................................................................................................... 35 Clinic Supervisor ............................................................................................................................ 37 Irene Feser ...................................................................................................................................... 38 Ronald Cooper ................................................................................................................................ 40 Marcy Perry .................................................................................................................................... 42 Timothy Johnston ........................................................................................................................... 44 Stephanie Chicko ............................................................................................................................ 46 Hipolito Cruz .................................................................................................................................. 49 Karen Koenig .................................................................................................................................. 50 Susan Pierce .................................................................................................................................... 51 Cynthia Chambers .......................................................................................................................... 55

Responses to the Preliminary Report and OIG Comments ............................................................... 57 Conclusions and Recommendations .................................................................................................. 59

OIG 13-029 May 7, 2014


FINAL REPORT RE: MISCONDUCT AND GROSS MISMANAGEMENT BY THE BROWARD COUNTY ANIMAL CARE AND ADOPTION DIVISION

SUMMARY

In October 2013, the Broward Office of the Inspector General (OIG) began an investigation based on allegations that the Broward County Animal Care and Adoption Division (ACAD) mishandled lethal controlled substances that had been entrusted to its care. Specifically, it was alleged that a number of ACAD Animal Care Specialists routinely violated county procedure by leaving the controlled substances, intended for euthanizing animals, in their county trucks or even in their personal cars, rather than locking them into a secure storage facility inside a county building.1 It was further alleged that at least one ACAD supervisor knew of this misconduct and did nothing to stop it.

The OIG investigation substantiated these allegations, and found that ACAD failed to take reasonable precautions against the misuse, theft, loss, or diversion of the drugs, which may have violated Florida law. Our investigation found that ACAD mishandled controlled substances by failing to enforce standard procedures for the storage and handling of the substances. This failure led to documented instances where drugs were left in a parking lot overnight or left in unlocked drug boxes in county vehicles, where they were susceptible to theft and abuse. ACAD also failed to institute even the most basic procedural safeguards, and had no process to verify that Specialists were using the drugs as claimed. Even after ACAD management was informed of repeated violations, it took no additional measures to ascertain the scope of the problem. ACAD also permitted unauthorized personnel to administer rabies vaccine in violation of Florida law and allowed its state and federally mandated permit and registration to lapse.

The OIG investigation also uncovered various other instances of misconduct and gross mismanagement. Many of the ACAD supervisors and employees admitted that during a period of at least the last two years, ACAD has failed to administer rabies vaccinations to animals prior to their return to owners, despite the fact that county law unequivocally requires that the vaccinations be made. In a random sampling of animals released to owners in 2013, the OIG found that few, if any, animals returned to their owners had been vaccinated against rabies. Even more disconcerting were multiple instances of animals with a known history of biting people that were released without being vaccinated against rabies. ACADs failure to perform its mandated function in this regard has recklessly created a public health and safety risk for all Broward residents and visitors.

1 The controlled substances are sodium pentobarbital and ketamine. The Controlled Substances Act, at Title 21, United States Code, Section 812, identifies sodium pentobarbital as a Schedule II controlled substance, and Ketamine as a Schedule III controlled substance. Ketamines anesthetic properties have occasioned its abuse by humans through its sale and use as an ecstasy drug. In addition, Ketamines effects can leave a user vulnerable to particular forms of crime, especially date rape. The Specialists were also given custody of the sedative Xylazine which, although not a controlled substance, is also known to be misused by humans as a recreational drug.

OIG 13-029 May 7, 2014 Page 1 of 60

BROWARD OFFICE OF THE INSPECTOR GENERAL FINAL REPORT RE: MISCONDUCT AND GROSS MISMANAGEMENT BY

THE BROWARD COUNTY ANIMAL CARE AND ADOPTION DIVISION

ACAD repeatedly, and in violation of the county code, waived impound and boarding fees and decided not to issue citations at the shelter for unregistered, unvaccinated or at-large animals returned to their owners. Rather, ACAD Director Susan Pierce admitted to instituting an informal policy of delayed citation which resulted in a backlog of unissued citations thatwitnesses stated ultimately fell off the books. The OIG found that the waivers were not documented in any manner that would enable the county to review the fiscal impact of the policy or audit the policys execution. In fact, the waivers were not based on any specified criteria and, according to witnesses, were granted to those owners who complained the loudest.

During the investigation, Director Pierce and other ACAD managers stated that their decision to waive fees and curtail the citation process was in response to the countys stated desire to one day transform the animal shelter into a no-kill shelter. After being questioned by the OIG, and upon further review, Director Pierce ultimately admitted that the county code did not authorize her policies. Further, Cynthia Chambers, Director Pierces superior, stated that until the issue was raised as a part of the OIG investigation, she had not known that ACAD was waiving any fees. She also stated that no member of the Broward County Commission has ever directed or requested ACAD to waive fees. The Mayor of Broward County confirmed that the Commission has never authorized or requested ACAD to delay citation of unregistered and unvaccinated animals. The Mayor noted that the concept of a no-kill shelter is merely aspirational because of the costs and that a lack of enforcement might only further delay attainment of no-kill shelter status.

On March 18, 2014, shortly before the preliminary version of this report was circulated, ACAD requested in a Broward County Commission agenda item that the County Attorney be directed to draft an ordinance which would give ACAD discretion to waive fines and fees for pet owners (Exhibit 1). The agenda item urges such action as essential for the successful establishment of a no-kill shelter, and notes that [c]urrently, full payment of all fines and fees is required before an animal can be returned to its owner, while omitting the fact that ACAD has been unilaterally waiving those fines and fees for years. Ms. Chambers stated that Director Pierce requested the agenda item because she was concerned about the findings of the OIGs investigation, and she wanted to get ahead of the OIGs report.

Regardless of the motivation for the agenda item, its lack of transparency is a disservice to both the County Commission and Broward residents. The motion did not inform the Commission that ACAD had already been engaging in the very same activities for which it was requesting authority. The motion also failed to address the deficiencies in ACADs current activities, such as a lack of criteria or documentation for the fees and fines waived by the department.

The OIG takes no position on a policy decision to implement a fee waiver or delayed citation program. But those policy decisions should be made by the informed vote of Browards elected officials. If it is determined that such programs serve a desired public purpose, they should be structured to transparently track fiscal impact, avoid arbitrary application, and avoid gross mismanagement. The division also needs to take more seriously its responsibility for the distribution, control and use of dangerous controlled substances. This report contains various recommendations which should be considered in the construction of a legally authorized waiver policy, if such a policy is desired, as well as safeguards to ensure compliance with local, state and federal controlled substance standards.

OIG 13-029 May 7, 2014 Page 2 of 60



OIG CHARTER AUTHORITY

Section 12.01 of the Charter of Broward County empowers the Broward Office of the Inspector General to investigate misconduct and gross mismanagement within the Charter Government of Broward County and all of its municipalities. This authority extends to all elected and appointed officials, employees and all providers of goods and services to the County and the municipalities. On his own initiative, or based on a signed complaint, the Inspector General shall commence an investigation upon a finding of good cause. As part of any investigation, the Inspector General shall have the power to subpoena witnesses, administer oaths, require the production of documents and records, and audit any program, contract, and the operations of any division of the County, its municipalities and any providers.

The Broward Office of the Inspector General is also empowered to issue reports, including recommendations, and to require officials to provide reports regarding the implementation of those recommendations.

ENTITIES AND INDIVIDUALS COVERED IN THIS REPORT

Broward County Animal Care and Adoption Division

ACADs stated mission is to provide shelter for lost and surrendered animals and promote successful adoptions that enhance the lives of companion animals and their humans. Among ACADs primary responsibilities are to:

Provide shelter and care to stray, surrendered and impounded dogs and cats; Coordinate the return of found animals to their owners; Offer programs and services that promote responsible pet ownership, including rabies clinics

and sterilization programs; and Enforce Broward County and State of Florida animal care ordinances and regulatory

requirements.

On October 1, 2013, ACAD became a stand-alone division within the Broward Environmental Protection and Growth Management Department (EPGM). Previously, it had been identified as Animal Care and Adoption Services (ACAS), within the Permitting, Licensing and Consumer Protection Division (PLCP). ACADs primary animal shelter facility is located in Fort Lauderdale, which is operated by three sections: Kennel Services, Clinic Services, and Customer Services. ACAD maintains a pharmacy at the shelter, which is licensed under Florida law. ACAD also maintained a field operations staff, including the Animal Care Specialists (Specialists), which was located at the Broward Government Center West Building (GCWB) in Plantation.

Cynthia Chambers

Ms. Chambers is the EPGM Director. Director Pierce reports directly to her.

OIG 13-029 May 7, 2014 Page 3 of 60



Susan Pierce

Director Pierce has been with Broward County for 24 years. Although ACAD underwent some restructuring between 2010 through 2012, Director Pierce had director-level responsibilities over the program as of mid-2010. She officially became Director of the new stand-alone ACAD division in October 2013. During the two years preceding her installation as the ACAD Director, Director Pierce was the PLCP Director, and also acted as the interim director of ACAS, ACADs predecessor agency.

Karen Koenig

Between May 2012 and April 2013, Ms. Koenig was the Administrator of ACAS, ACADs predecessor agency. She reported to Director Pierce.

Hipolito Cruz, Jr.

Between March 2011 and October 2013, Mr. Cruz was a Section Manager for the PLCP whose responsibilities included some oversight of the former ACAS section. Mr. Cruz has been a county employee for approximately 18 years, during which time he has served in a variety of positions relating to code enforcement.

Stephanie Chicko

Ms. Chicko is the ACAD Administrative Manager. She has served in that capacity for ACADs predecessor agencies since 2009.

Timothy Johnston

Dr. Johnston is the ACAD veterinarian. He has been employed as a veterinarian for the county since August 2002.

Marcy Perry

Ms. Perry is the Clinic Manager at the ACAD shelter.

Ronald Cooper

Mr. Cooper has been the Kennel Services Supervisor at the ACAD shelter since the summer of 2013. He previously served as the Supervisor of Field Operations, and was responsible for supervising the Specialists.

Irene Feser

Ms. Feser has been the Supervisor of Field Operations since the summer of 2013.

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The Clinic Supervisor

The Clinic Supervisor has oversight responsibilities for the Clinics day-to-day operations.

The Customer Care Specialist

The Customer Care Specialist coordinates ACADs licensing and citation functions.

The Lead Veterinary Technician

The Lead Veterinary Technician (Lead Vet Tech) assists Dr. Johnston, and is responsible for dispensing drugs to the Specialists.

The Senior Animal Care Specialist

The Senior Animal Care Specialist (Senior Specialist) assists Ms. Feser in addition to performing the duties of a Specialist.

The Animal Care Specialists

ACAD employs thirteen Field Operation Specialists. They perform a variety of animal control and care duties, both at kennels and in the field, including euthanizing animals when required. The Specialists are issued euthanasia lock boxes (ELBs) that contain controlled substances.

RELEVANT GOVERNING AND ADMINISTRATIVE AUTHORITIES

Permitting for Animal Control Agencys Purchase and Use of Controlled Substances

The Board of Pharmacy has adopted rules for the issuance of permits authorizing the purchase, possession and use of controlled substances in animal control agencies. Florida Statutes 828.055. Applicants must also obtain a DEA Animal Shelter registration. Florida Administrative Code (F.A.C.) 64B16-29.002. Florida Statute 828.055(3) states that the department may deny a permit or refuse to renew the permit of any permittee, if it determines that:

(b) The applicant or permittee has failed to take reasonable precautions against misuse, theft, loss, or diversion of such prescription drugs;

(d) The applicant or permittee has failed to follow the rules of the Board of Pharmacy regarding proper storage and handling of such prescription drugs

The department may also elect to revoke, suspend an existing permit, and may fine, place on probation, or otherwise discipline any permittee.

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Storage of Controlled Substances

Florida Statute 828.055(1)Controlled substances and legend drugs; permits for use:

The Board of Pharmacy shall adopt rules providing for the issuance of permits authorizing the purchase, possession, and use of sodium pentobarbital, sodium pentobarbital with lidocaine xylazine ketamine by county or municipal animal control agencies for the purpose of euthanizing injured, sick, or abandoned domestic animals which are in their lawful possession or for the chemical immobilization of animals. The rules shall set forth guidelines for the proper storage and handling of these prescription drugs and such other provisions as may be necessary to ensure that the drugs are used solely for the purpose set forth in this section.

F.A.C. 64B16-29.005 Storage:

All controlled substances, medicinal drugs or legend drugs shall be stored in a safe place. At a minimum, this shall require that the drugs be kept in securely locked cabinet within a locked storage room

Veterinary Medical Practice

Florida Statute 474.203(5)(a) requires that [O]nly a veterinarian may immunize or treat an animal for diseases that are communicable to humans and that are of public health significance.2 Pursuant to F.A.C., Rule 61G18-17.006, rabies is a communicable disease for which only a veterinarian may immunize or treat an animal.

Local Regulation of Fines, Fees and Vaccination

The Code of Ordinances of Broward County (Code), Chapter 4, Animals, provides the following:

Sec. 4-3. Dogs at large prohibited:

(h) An officer shall issue a citation for any dog found by the officer to be at large Additionally, the officer may seize and impound the at-large dog.

Sec. 4-5. Impoundment:

(d) Dogs or cats impounded by the Division shall be released to their owner upon presentation of proof of ownership and after proper vaccination, licensing, and payment of impounding fees and redemption charges established by resolution of the Commission (Emphasis added).3

2 Florida Statute 828.30(1) also requires that all dogs, cats and ferrets 4 months of age or older be periodically vaccinated against rabies by a licensed veterinarian.

3 These vaccination, registration and payment requirements are reiterated in Sec. 4-7(b) relating to owners redemption of dogs and cats.

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Rabies vaccinations are required by Sec. 4-10 of the Code. It requires owners to initially vaccinate their dogs, cats and ferrets against rabies by four (4) months of age and revaccinate every 12 months thereafter.

Registration of dogs and cats is governed by Sec. 4-11, which requires registration with Broward County by four (4) months of age.

The ACAD Field and Dispatch Procedures Manual

ACAD has developed the Field and Dispatch Procedures Manual (Manual), which sets forth the policies and procedures with which ACAD personnel are required to comply, including various Standard Operating Procedures (SOPs). The Manual contains an SOP titled Procedures For Handling/Storage Of Euthanasia Equipment (the Handling SOP) which prescribes the manner in which the Specialists are required to handle and store the controlled substances that are assigned to them. After listing the equipment provided to them, which includes Locker with padlock and key, an Internal storage box and key, vials of Fatal Plus solution and Pre-Euthanasia solution and a Log Book, the Handling SOP states:

All usage must be logged in the book provided. This should include the date, amount used, animal ID# of patient and balance remaining after use. When the officer is off duty the euthanasia equipment must be placed in the storage box and locked and then placed in the designated locker and padlocked. (Emphasis added). The officer will keep copies of both keys and a supervisor/clinic coordinator will keep copies as well. During the officers on duty time the equipment must be kept locked in the vehicle lock box provided. When leaving the vehicle external doors must be locked to insure compliance with the regulation. The purpose of these procedures is to discontinue the complaint that another officer may use equipment and either does not replace it or neglects to log the usage.

INVESTIGATION

Investigation Overview

This investigation is predicated on information alleging that ACAD mishandled controlled substances entrusted to its care. The OIG investigation substantiated the information, and also identified additional instances of misconduct and gross mismanagement, including the failure to adequately monitor and account for the use of the controlled substances; the unpermitted operation of the clinics pharmacy at the county animal shelter; the failure to provide required rabies vaccinations; the administering of rabies vaccinations by unauthorized personnel; the failure to impose and collect required fees and charges; and the failure to issue and enforce citations for unvaccinated, unlicensed and at-large dogs.

The investigation involved the review of substantial documentation by OIG Special Agents including, but not limited to, ACAD records, manuals, training materials, SOPs, and emails; Broward County Human Resources Division investigative materials; federal, Florida, and county law; authorities governing the

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conduct of animal care shelters and veterinarians; and GCWB security camera footage. OIG Special Agents also conducted interviews of current and former ACAD management officials and employees.

Mishandling of Controlled Substances

Before 2011, the Specialists locked up the euthanasia drugs in their county trucks after their shifts were over. The trucks had a storage box that was bolted down in the truck. As of March 1, 2011 the policy was changed and the Specialists were no longer permitted to leave the controlled substances in the trucks. Instead, ACAD issued a new policy for the handling and storage of euthanasia equipment, including controlled substances. (See policy attached as Exhibit 2). The stated purpose for the change was to address an issue of potential undocumented use of the controlled substances. The new policy required that after every shift the Specialists bring the ELBs into the GCWB and store them under lock and key in secured stationary lockers. Specifically, the new policy mandated that [w]hen the officer is off duty the euthanasia equipment must be placed in the storage box [the ELB] and locked and then placed in the designated locker and padlocked. The only time a Specialist was not required to lock the ELB in a stationary locker was when he was assigned to the on-call shift.

1. Most of the Specialists Regularly Violated the Handling SOP

As a part of the investigation, OIG Special Agents personally conducted surveillance of the Specialists as they began and ended shifts at the GCWB. OIG Special Agents also reviewed hours of GCWB security camera footage, and confirmed that these Specialists were not bringing their ELBs into the building and locking them into their storage lockers at the end of their shifts. The OIG determined that nine of the thirteen Specialists monitored by the OIG violated the Handling SOP: rather than bringing the ELBs into the GCWB and locking them in their security lockers, they left them in county trucks parked outside or stored them in their personal vehicles.

After reviewing the evidence with OIG Special Agents, the Specialists interviewed by the OIG admitted that they did not regularly bring their ELBs into the GCWB and lock them up. They also admitted that they were aware of the Handling SOP but simply ignored it. The excuses they offered for their misconduct included pure laziness, it is just easier, for convenience, saving time, and everyone else was doing it, I hate going into the building, and even that the Handling SOP is dumb and makes no sense. Nevertheless, each of the Specialists also acknowledged that the controlled substances contained in their ELBs were subject to illegal misuse, especially ketamine, which they stated was commonly referred to on the street as Special K.

2. ACAD Administrators Failed to Enforce the Handling SOP

The evidence obtained by the OIG reveals that on numerous occasions since 2012, ACAD management had been informed, both verbally and through written notice and complaint including a Human Resources report of investigationthat the Specialists were mishandling their

OIG 13-029 May 7, 2014 Page 8 of 60



ELBs. Yet, in each of those instances, ACAD failed to take any disciplinary action.4 Between September 2012 and April 2013, one Specialist (Specialist A) witnessed three separate incidents in which other Specialists left their ELBs unlocked in their county trucks overnight. She reported each incident to her supervisors, including Mr. Cooper, but ACAD took no disciplinary action against the Specialists. The first incident occurred on September 1, 2012, after Specialist A entered a county truck and noticed that there was an ELB on the floor under the passenger side seat. She opened the unlocked ELB and saw that it contained the usual controlled substances. She sent an email to supervisors to which she appended photographs of the controlled substances. (See photographs attached as Exhibit 4).

On March 23, 2013, Specialist A verbally reported a second violation of the Handling SOP to Mr. Cooper after she observed an ELB wide open with controlled substances in plain view on the passenger side floor of a county truck assigned to another officer who had the day off. She also showed Mr. Cooper a photograph of the open ELB (Exhibit 5).

On April 11, 2013, Specialist A observed a third violation of the Handling SOP, when she again discovered an unlocked ELB in a truck she was taking out on duty. She did not photograph the ELB, but emailed Mr. Cooper, asking shall I bring it in? Mr. Cooper responded, Ill get it.

The OIG has determined that no disciplinary action was taken in response to the three incidences. Mr. Cooper admitted to OIG Special Agents that after he retrieved the unlocked ELB, he later met with the offending Specialist and told him not to leave the ELB in the truck, but that no written disciplinary action was requested or implemented. When another specialist (Specialist B) submitted a complaint to Mr. Cruz regarding Mr. Coopers lack of action, the complaint was forwarded to Human Resources, which undertook an investigation.5 Thereafter Human Resources issued a memorandum in which it concluded that when those instances had been brought to Mr. Coopers attention, he immediately verbally counseled the offending Specialists, and that, since management was not aware of any reoccurrences of this concernno further corrective action has been taken.6

Indeed, after Mr. Cooper was replaced as Supervisor of Field Operations, the new supervisor did request disciplinary action in another documented incident relating to the mishandling of an ELB. Nonetheless, ACAD administrators failed to execute disciplinary action. In August 2013, Ms. Feser filed a request for disciplinary action against a specialist (Specialist I) for leaving her ELB in the parking lot overnight. She did so after the Senior Specialist informed her that a GCWB security officer found an ELB in the parking lot next to one of the county ACAD trucks over the weekend.

4 During the course of the OIGs investigation, Director Pierce sent an email to ACAD staff stating that [i]t has been reported that the procedures and requirements for handling euthanasia materials are not being followed and as a direct result, staff is not in compliance with [the Handling SOP]. (See March 5, 2014 email from Ms. Pierce, attached as Exhibit 3). Despite the evidence to the contrary, the email appears to suggest that ACAD management has only recently been notified of violations of the Handling SOP. The email describes various corrective measures contemplated by ACAD, including an inspection and inventory of all ELBs, and the forthcoming transfer of all Specialists from the GCWB to the shelter.5 The complaint also alleged several other allegations relating to what Specialist B characterized as the inequitable treatment of other ACAD employees, none of which are the subject of the OIG investigation.6 July 30, 2013 Memorandum to Susan Pierce, Director PLCP, from Rita Russo, Human Resources Analyst.

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Ms. Feser contacted Mr. Cruz and Human Resources to advise them of the incident. She also initiated the necessary paperwork to request disciplinary action. Ms. Feser recalled participating in a pre-disciplinary meeting with Specialist I and a Human Resources staff member and submitting the necessary paperwork to her superiors. Ms. Feser was later informed by Human Resources that the time period to take action against Specialist I had expired and thus ACAD was unable to impose any disciplinary action. Specialist I confirmed that she was never disciplined for violating the Handling SOP. The OIGs review of Human Resources records confirmed that the Specialist was not suspended for violating the Handling SOP.

As indicated above, the OIG independently confirmed that the SOP was routinely violated, a fact that could have been easily ascertained by ACAD at any time since it was first notified by Specialist A.

3. ACAD Failed to Monitor Compliance with the Handling SOP

The OIG confirmed that ACAD has not instituted any process to document the proper storage of ELBs. Director Pierce stated that ACAD has stressed to supervisors they are responsibleto be held accountableto take drug stuff very serious. She also stated that the Manual contains an SOP requiring senior ACAD personnel to conduct random inspections of the trucks, lockers, and equipment. She felt confident that ACAD supervisors conducted such inspections, although she did not know how often they did.

The OIG investigation revealed that the manual contains no SOP requiring the inspections of lockers to ensure the ELBs have been properly stored. We also discovered that Director Pierces confidence that the inspections were nonetheless being conducted was misplaced: Ms. Feser and Mr. Cooper both stated that they did not conduct inspections to ensure that the Specialists were locking up their ELBs every night.7 The Senior Specialist also admitted that she did not inspect the lockers, but stated that once in a blue moon she inspected the trucks. She added that Im not sure if theyre [locking up their ELBs] or not and I wouldnt know unless I got a complaint.

Finally, ACAD administrators have been, at best, inconsistent in communicating the need for strict compliance with the Handling SOP; at worst, they have derided it and condoned non-compliance. One Specialist stated that she had been informed during training by the Senior Specialist that bringing the ELB into the GCWB at shifts end was preferred, but you can also take it with you. Another stated he was told that as long as the ELB is locked up in the county truck then it was okay. And Mr. Cooper stated that if they did leave the ELBs in their trucks, then it would be okay with me as it still is locked behind two locks. He acknowledged that his view contravened the Handling SOP, but maintained that if it were up to him, it still would be okay as it would fall under the two locking method of securing the ELBs.

7 Ms. Feser indicated that when she became the new Supervisor of Field Operations in the summer of 2013 she had not been instructed to conduct inspections of the lockers or controlled substance storage.

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Failure to Monitor, Control and Properly Administer Use of Controlled Substances

Our investigation revealed that ACAD has failed to adequately monitor and account for proper use of the controlled substances. ACADs failure in this regard may have violated Florida law, which requires that it take reasonable precautions against misuse, theft, loss, or diversion of the drugs.8

1. ACAD Failed to Impose Adequate Internal Controls to Ensure Proper Distribution of Controlled Substances

After the Specialists are certified to perform euthanasia on animals they are provided with an ELB, a drug log book, and the euthanasia and sedative drugs. Dr. Johnston stated that when he issued the drugs to the Specialists, he provided the drugs from the clinic pharmacy and then documented the issuance of the drugs by making notations in both the clinical drug log bookkept at the shelter clinicand in the Specialists drug log books. He then instructed the Specialists that when they use any of the drugs in the field they must subtract the amounts in their books until it reaches zero. However, he acknowledged that he delegated the responsibility for distributing drugs to the clinics veterinarian technicians, and he noted that it has been at least three years since he has personally issued drugs to the Specialists. Since then, the veterinarian technicians have handled refilling drugs for the Specialists and he stated that he hoped that his vet techs are doing it [his] way.

Multiple Specialists stated that when they need to refill their drugs, theynot the veterinarian techniciansmake the entries in their own drug log they books.9 The Lead Vet Tech stated that the Specialists were supposed to record the amounts of drugs they use in their drug log book every time they administer drugs in the field; she was not sure if they were doing this, but hoped that they were. Dr. Johnston, the Lead Vet Tech, and the Specialists also stated that the veterinarian technicians do not provide any reconciliation of the Specialists drug log books to the clinical drug log book. Nor have the Specialists drug log books ever been audited or inspected by ACAD management or the veterinary staff. As one Specialist observed, his colleagues and he are on the honor system.

2. ACADs Computer System was Not Properly Used to Verify or Track Drug Usage

ACAD utilizes a computer system known as the Chameleon system to perform a variety of functions, including tracking the Specialists use of euthanasia and sedative drugs. The manner in which ACAD uses the Chameleon System for this purpose is deficient and vulnerable to abuse.10

In addition to the drug log books, the Chameleon system is supposed to track drug use by the Specialists. Director Pierce identified it as the official mechanism ACAD used to track usage of

8 Florida Statute 828.055(3)(b). 9 The Lead Vet Tech maintained that she writes the refill amounts in the Specialists drug log books as well the clinical

drug log book, but she also acknowledged that she was not the only veterinarian technician who provided drugs to the Specialists.

10 In 2010, the County Auditor issued a report that was critical of ACADs use of the Chameleon system in connection with

certain selected business practices.

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the drugs. However, ACAD relies upon the Specialists themselves to enter that information into Chameleon.11 There are two dosage fields in the Chameleon system that are used to record how much of the drugs have been utilized: one for the euthanasia drugs, and another for the sedative drugs. However, the majority of the Specialists have not been formally trained in entering the data,12 and there exist no written materials to provide them with any direction and guidance. The Specialists all stated that they have never actually been instructed as to which field they should use for which drugs. The Lead Vet Tech acknowledged that this creates an inherent problem for anyone attempting to reconcile the drug amounts, since the data may not be entered into the Chameleon system in a uniform manner.

3. ACAD Distributed Controlled Substances to Specialists Without Verifying that the Drugs Were Properly Used

When a Specialist runs out of the drugs he was previously provided, no attempt is made to ensure that the drugs were properly used in verifiable animal control activities. In order to get new drugs, some Specialists only displayed an empty vial to a veterinary technician, and showed a log book that reflects a zero amount. The Specialists are not required to turn in the empty vialssome specialists admitted to receiving drugs without even displaying an empty vialand no attempt is made by the veterinarian technicians to reconcile the Specialists drug log books to the clinical drug log book. Instead, they merely check the drug log bookwhich, of course, was filled out by the requesting Specialistto make sure it shows a zero amount. No one verifies proper use of the drugs with the Chameleon system. As the Lead Vet Tech described, she then matches the amounts in the drug log book to the amount remaining in the bottle. She stated she eyeballs it.

Even though the Specialists are required to cross-reference their drug use information into the Chameleon system with the information in their drug log books, in practice, the clinic supervisory staff doesnt even bother to review it. The veterinarian technicians do not provide any reconciliation of the Specialists drug log books to the clinical drug log book to the Chameleon system. Dr. Johnston stated that he was not aware of any Chameleon data reports that are provided on a weekly, monthly, or annual basis that show drug dosage amounts. And the Lead Vet Tech admitted that the veterinarian technicians never even review the Chameleon system for drug dosage amounts.

Dr. Johnston believed that when refilling drugs for the Specialists, the veterinarian technicians will remove a bottle of euthanasia or vial of sedative drugs from the clinic pharmacy inventory and will make notes in the clinical drug log book of the drugs provided. He did not know whether they wrote the refill amounts in the Specialists drug log books. He also did not know whether the Specialists would bring in their empty drug bottles or vials, but again, he hoped they did. He added that the clinic accounts for the drugs by the number of bottles and vials used and not by dosage amounts. The clinic only uses the handwritten clinical drug log book to reconcile the drug inventories, and does not utilize the Chameleon system for that purpose.

11 Dr. Johnston stated that he hoped the Specialists were logging that information into the Chameleon system, but he was not sure if they were.

12 Nor has Dr. Johnston, who candidly admitted that he has never been trained to use the Chameleon system. According to

Ms. Perry, she began providing Chameleon training to the newly appointed specialists in the past year.

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4. ACAD Allowed Rabies Vaccinations to Be Administered by Unauthorized Personnel

Despite the requirement of Florida law that only a licensed veterinarian may immunize or treat an animal for rabies,13 ACAD has allowed Specialists and veterinary technicians to administer rabies vaccinations to hundreds of Broward pets during monthly promotions at animal clinics throughout the county.

ACAD management advised OIG Special Agents that the Specialists were not authorized to administer the rabies vaccination at the promotions, although it allowed the veterinary technicians to do so. Director Pierce, in particular, said she has never heard of a Specialist administering the rabies vaccine, and would be shocked and would be rather upset if she finds this out. Nevertheless, some of the Specialists admitted that they, too, administered vaccinations at the promotions.

Dr. Johnston stated that he gave permission to the veterinarian technicians to administer the rabies vaccinations, but not the Specialists, and was not aware that any of the Specialists were administering the rabies vaccinations at the promotions.14 In contrast, the Clinic Supervisor stated that she and Dr. Johnston did allow certain Specialists, as well as the veterinarian technicians, to administer vaccinations when Dr. Johnston was present at a promotional event.

Dr. Johnston and the Clinic Supervisor both admitted that they were not aware that Florida law mandates that only a licensed veterinarian can administer rabies vaccinations. They both stated that due to the OIG investigation, an email was sent on December 14, 2013 to ACAD staff acknowledging the law, and stating that only a licensed veterinarian could administer the rabies vaccinations (Exhibit 6).

5. Failure to Comply with Federal and State Permitting Requirements

The OIG investigation determined ACAD allowed its controlled substance permit and registration to expire. In the summer of 2013, ACAD was prohibited by the DEA from engaging in any regulated activity with controlled substances because the animal shelter clinic failed to renew its DEA registration. A letter from the DEA dated August 7, 2013 notified ACAD that it was no longer authorized to engage in any regulated activity with controlled substances or List I chemicals under this registration (Exhibit 7).

Ms. Chicko stated that after ACAD received the letter, she contacted the DEA and was told how to get the DEA registration renewed. While researching this matter, she also learned that the shelters state pharmacy permit had lapsed and that it had not been renewed for two years. ACAD then had to go through the entire process of getting a new state pharmacy permit and DEA registration, rather than simply request a renewal. Although ACAD has now rectified those problems, it is unacceptable that they were ever allowed to arise.

13 F.A.C. 61G18-17.006(3). The Florida Animal Control Association (FACA) also states that a rabies vaccination must only be administered by a licensed veterinarian.

14 Dr. Johnston stated that he attended the monthly rabies promotions for the first eight or nine years he was working for the county, but he has not been to one in the past three years.

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Ms. Chicko advised that Ms. Perry and the clinic staff should have been on top of this issue and that they should have been aware of all the necessary licenses and expiration dates. She observed that there were no warnings in place, no discussions with staff on renewal of licenses and that it was a duty that someone used to do in the past down the line. She noted that she has now created a spreadsheet for all of the necessary federal, state and local licenses with their expiration dates. However, she did not know if ACAD had violated any laws on purchasing and storing controlled substances because Dr. Johnston had a valid veterinarian license and DEA registration which allowed him to purchase and store controlled substances.

The Clinic Supervisor stated that during the time period the pharmacy did not have its DEA registration number she was not sure what DEA registration number was used to purchase the drugs, but assumed it was either the clinics or Dr. Johnstons. She explained that the drug manufacturers had Dr. Johnstons individual DEA registration number on file and when drugs were ordered, they did not ask for a specific DEA registration number. She also stated that she did not have to order any euthanasia drugs during the time period the DEA registration was expired because they had enough in inventory, but she did purchase some of the sedative drugs.

Dr. Johnston was first apprised of the shelters DEA registration lapsing when he was carbon copied on an email, which advised that ACAD had just received a letter from the DEA stating the registration had expired. He stated that he was shocked when he learned the DEA registration had expired, and that someone dropped the ball. He also stated that Director Pierce, Ms. Chicko, and Ms. Perry were not aware that the DEA registration and the pharmacy permit needed to be renewed, but maybe they should have been.

Dr. Johnston advised that the drug manufacturers had his individual DEA registration number on file when drugs were ordered. He stated that the shelter needs a state pharmacy permit to buy the euthanasia drugs. The shelter uses his veterinarian DEA registration number to purchase the sedation and other medical drugs. Once he learned that the shelters DEA registration had expired, he also learned that the state pharmacy permit had also expired. Dr. Johnston stated that the shelter could not get the DEA registration renewed until it got a new pharmacy permit. He noted that the shelter had to purchase the euthanasia drugs once during the time period the DEA registration was expired and that he had to personally file a form with the DEA before the purchase could be made.

Failure to Administer Rabies Vaccinations

County law requires that dogs or cats impounded by ACAD be released to their owner only after proper vaccination. 15 All of the interviewees agreed that the Code plainly requires ACAD to give rabies vaccinations to animals before they are released to their owners. Indeed, ACADs former administrator, Karen Koenig, stressed to OIG Special Agents that it is imperative that all animals brought to the shelter receive rabies vaccination, preferably upon entry. Yet, many ACAD supervisors and employees admitted that ACAD has failed to administer rabies vaccinations to animals prior to returning them to their owners.

15 Code Sec. 4.5 (d). FACA also recommends that all dogs and cats released from animal shelters be vaccinated prior to their release.

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ACADs failure to perform its mandated function in this regard has recklessly created a public health and safety risk for all Broward residents and visitors.

In a random sampling of animals released to owners in 2013, the OIG found that few, if any, animals returned to their owners had been vaccinated against rabies. Even more disconcerting were multiple instances of animals with a known history of biting people that were released without being vaccinated against rabies. According to ACAD records obtained by the OIG, the biting animals we identified continue to be unregistered and unvaccinated. The owners had not been cited as of March 2014.

Director Pierce stated that she did not know whether ACAD was administering the vaccinations to animals before their release.16 Dr. Johnston stated he had no knowledge of the shelter returning animals back to their owners without giving rabies vaccinations and it was a surprise to him. He explained that I assumed they were all getting done; I thought it was a requirement before they left. He added that he did not know the reason for the policy of releasing animals without giving a rabies vaccination, nor did he know who authorized it, but stated, Im surprised, hard to believe we are doing it. He stressed that no one in management brought this issue to his attention.

Ms. Perry, Ms. Feser, Mr. Cooper and the Senior Specialist all confirmed that ACAD was no longer giving the vaccinations, although they could not point to any SOP or any other writing that authorized it to stop. Some ACAD personnel admitted they were not even aware they should check the status of an animals rabies vaccinations prior to releasing the animal to the owner. However, the Senior Specialist stated that when the policy not to vaccinate was established it was verbally communicated to staff in a meeting in October 2011. Numerous witnesses told the OIG that ACAD management wanted to make the agency more accepting to the public and wanted the kennel to be known as a happy place for the public, and that enforcement was viewed as a negative. Under the policy, the kennel supervisory staff would return animals to owners without the required rabies vaccinations. The kennel supervisors were supposed to provide a log of these unvaccinated returned animals and their owners to the Specialists, who would presumably then go out to the owners residences and provide 30-day warning notices to them advising that they had to get their animals vaccinated for rabies.

The Senior Specialist also stated that at a staff meeting on December 14, 2013after the OIG had questioned the release of unvaccinated animalsMs. Chicko acknowledged that the animals were being released back to the owners without having been vaccinated, that it was a problem, and that they needed to get back to the practice of vaccinating prior to release. Ms. Chicko has since apprised the OIG that ACAD recently informed the shelter staff that they are no longer permitted to return animals to their owners without the animals being vaccinated for rabies.

16 A memo attributed to Director Pierce, dated May 7, 2013, states that Specialists are required to ensure that animals are vaccinated prior to being returned to their owner. However, the memo was never finalized and distributed to staff (Exhibit 8).

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Failure to Collect Required Fees and Charges and to Issue and Enforce At-large Citations

County law requires that owners seeking release of their animals from the ACAD shelter pay various fees, including a reclaim fee, rabies vaccination or registration fee, and boarding fees, if applicable.17 A schedule of the fees, which are established by resolution of the Broward County Commission, is attached as Exhibit 9. County law also requires that ACAD shall issue a citation for any dog found to be at-large. 18 Nonetheless, the division has often waived boarding and impound fees, and it has regularly neglected to issue citations for unregistered, unvaccinated or at-large animals.

1. ACAD Waived Fees and Citations Required by Code

According to witnesses, on or about October 2011, when PLCP took over responsibility for ACAD, Director Pierce created a new policy enabling supervisors to return animals to their owners without requiring the payment of impound or boarding fees, consistent with the notion of making the kennel a more customer-service oriented place. Ms. Perry affirmed that she has waived hundreds of fees as a manager of the shelter in the past and that it is possible that she did so without the animals having the rabies vaccination or being properly licensed. Waiver of fees could also include reducing the fee by subtracting a few days from the boarding fees. She estimated there were thousands of cases in which fees could have been waived by ACAD managers or supervisors.

Ms. Perry stated that ACADs upper management did not like getting letters from the commissioners requesting information on animal care cases that they had received from the public. The public would criticize ACAD for having to pay fees to get their animals back, so the upper management team would come down on the managers and supervisors, asking them why didnt you take care of this problem or why didnt you just give it to them can they pay half. After this happened a hundred dozen times it just transitioned into the managers and supervisors having the authority to waive fees. Ms. Perry also stated that the upper management team also did not want the owners leaving without their animals.

Director Pierce admitted that she was responsible for issuing the waiver policy but claimed that it was in response to an April 2012 no-kill Commission resolution. Although her policy predates the aspirational resolution, she stated that the purpose of her waiver policy was to advance the Commissions desire to turn the ACAD shelter into a no-kill shelter. According to Director Pierce, the theory was to lower the intake of animals and reward responsible pet owners with not having to pay the fees. Director Pierce used the term freebies when discussing the fee waivers. The freebies included fees for rabies vaccinations, license registrations, and micro-chips, and at-large fines and boarding fees. An OIG review of the resolution reveals that it does not authorize the fee waiver or delayed citation program.

Further, the OIG could find no evidence that Director Pierces policy contained any criteria or processes to ensure a justified and equitable waiver of fees. Ms. Chicko stated that ACAD wanted the public to witness happy exits of animals. If an owner did not want to pay the fees, the owner

17 Code Sec. 4.7 (b). 18 Code Sec. 4.3 (h).

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would argue with the customer services representative and there was a lot of yelling and emotional outbursts by the owners. She claimed that the shelter began experiencing owners just walking out of the shelter and stating, just take my animal, I cant pay for these services, and this would justify the waiver of fees. On the other hand, as numerous ACAD staff observed, if an owner did not question fees or fines, she was routinely required to pay them in full. Regarding this lack of equitable treatment of those owners who were required to pay, Specialist B succinctly observed how would they feel if they knew so many didnt get fined?

2. ACAD Allowed a Backlog of Unregistered, Unvaccinated or At-Large Animals to go Without Enforcement

According to Director Pierce, another aspect of her policy was a program in which the kennel staff would return animals back to the owners upon proof of ownership. The animal would be released with a 30-day warning to allow the owner to comply with registration and vaccination requirements and citations may not be issued at the time of release. The owners were informed that if they complied with the 30-day notice and got their dogs licensed and properly vaccinated for rabies within the 30-day period, they would not be given a citation. The county would also waive the at-large citation for animals impounded at-large. If the owners did not comply within the 30-day period, then the kennel staff would presumably notify a Specialist to make contact with the owners at their homes and issue the necessary citations. Director Pierce also stated that the division utilized the mail to send out citations.

Ms. Chicko stated that a unilateral decision had been made to remove the Specialistsresponsible for enforcementfrom the shelter and relocate them to the GCWB, and that the customer service staff would no longer issue at-large citations to the owners picking up their animals at the shelter.

The process for delayed issuance of citations was flawed, resulting in many citations not being served and collected. 19 When ACAD stopped issuing citations at the shelter and began requiring specialists to follow-up on animals that had been returned to their owners (RTO), it placed a new and significant burden on the Specialists, who have found it difficult to issue follow-up citations20 in addition to handling calls for traditional animal care services. They admitted to the OIG that they did not view follow-up citations and 30-day warning delivery duties as high priorities.

Mr. Cooper echoed the Specialists assertion that the follow-up citations were not a priority and that the management team did not put a major emphasis on ensuring the citations were issued. He also stated that his management team did not put a charge into him to follow up with the RTO at-large citations. He admitted that he was part of the management team, and he did not put pressure on his Specialists to issue the citations. Mr. Cooper stated that the RTO follow-up citation list continued to grow and that every day there was a new list. He advised

19 For a more detailed description of the delayed-citation process, see the interview summary of the Customer Services Specialist at page 35.

20 In the Interview Summaries below, Specialists often refer to the follow-up citation process as RTO at-large citations or other derivations of the same.

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that he started hearing from the Specialists that this is crazy. Mr. Cooper stated that the Specialists could only do what they could do in their eight-hour shifts; no overtime was granted to them to handle the follow-up citation overload. He further stated that the increased back log continued and then they just fell off the books.

The undistributed memo attributed to Director Pierce acknowledges the program of delayed citation and indicates that Supervisory approval is required for release without vaccination or licensing (Exhibit 8). The memo also acknowledges that there are concerns with the RTO process. However, the draft memo does not address criteria for waiver of fees and citations. It also does not address the backlog of follow-up citations which has been identified by witnesses.

3. ACAD Administrators Lacked the Authority to Institute Fee and Citation Waivers

During her interview, Director Pierce stated that she would provide the OIG the county ordinance and county administrative code that allowed her to institute the processes described above. Director Pierce subsequently acknowledged to the OIG that the waiver policy is not legally authorized. (See email from Director Pierce to the OIG dated December 18, 2013, attached as Exhibit 10). In her email, Director Pierce admitted that the correct blanket policy is only the commission has the authority to waive or release a fine, unless the authority had been delegated. 21 However, she ambiguously cites to a free ride home program, recently authorized by Mayor Sharief, presumably as a source of authority for the waivers and lack of citations in which ACAD had been engaged under Director Pierces management.

The OIG reviewed the motion cited by Director Pierce as the free ride home program and interviewed the sponsor of the item, the Mayor of Broward County. The Mayor confirmed that she has never authorized or requested ACAD to waive any fees other than those waivers specifically authorized in official Commission actions. Further, she verified that her motion did not contemplate the release of unregistered, unvaccinated animals without being cited. The concept of free ride home applied to animals that were properly registered and vaccinated but got away from their homes. The Mayor indicated that she had been informed by ACAD that there were a large number of unregistered animals in Broward County. It was her position that more enforcement, not less, was needed to get animals properly registered and vaccinated, which is why she sought additional specialist positions. The Mayor noted that the concept of a no-kill shelter is merely aspirational because of the cost, and that a failure to cite delinquent owners and to apply the proper fees to impounded animals would only further hinder the goal of becoming no-kill shelters. Further, she stated that if any motion of the Commission contradicted the requirements of the Code, it would be the responsibility of the department in question to bring the conflict to the Commissions attention.

Ms. Chambers also acknowledged that there are no ordinances that allow managers and supervisors to waive impound and boarding fees or to issue 30-day warnings instead of citations for

21 The only waiver authority Ms. Pierce could cite was Code Sec. 4-33, which allows for fee waivers for unsterilized dogs and cats, and even then only if the owner presents proof of sterilization within 30 days.

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unregistered, unvaccinated or at-large animals. She advised that only the County Commission can vote to change a standing ordinance via resolution. She stated that she was not apprised of ACAD waiving fees until late February 2014, when Director Pierce brought her the agenda item (Exhibit 1) for review and approval. Ms. Chambers stated the agenda item was requested by Director Pierce based upon the findings of the OIGs investigation, because Director Pierce wanted to get ahead of the OIGs report. She further stated that after reading the agenda item and speaking with Director Pierce about the details of the OIG investigation, she recognized that ACAD could not waive fees or issue 30 day warnings. She added that its a management issue, not staff.

4. Due to Mismanagement, the Potential Financial Loss Cannot be Determined

It cannot be disputed that ACADs failure to impose fees and charges, and its waivers of citations for at-large, unregistered and unvaccinated animals, has caused a financial loss to animal care funding. However, in addition to lacking uniform criteria for fee waivers, ACADs waiver policy contained no mechanism to consistently document the waiver of fees and lack of citations. Ms. Perry stated that when an animal was returned to the owner and the owner did not want to pay the fees, a customer service representative would ask a supervisor for approval to waive a fee. She explained that the customer service representative and the supervisor would review the case in the Chameleon system and then whatever waiver was recommended would be taken off the customers bill. She also stated that the supervisors did not always enter their names or provide an explanatory note in the system for every waiver; nor were the supervisors required to.

A review of a number of RTOs with no associated charges revealed that comments relating to waivers were infrequently entered and that, in most cases, it was impossible to determine if an owner had not been charged because no fees were due or if the fees had been waived. This failure would prevent the County from ascertaining the potential fiscal impact associated with the waiver policy.

The OIG attempted to obtain data in a variety of other forms that might lead to an estimate of losses, but limitations in the divisions database, as well as the lack of tracking and documentation, presents an obstacle to assigning a number to the financial loss. For example, ACAD personnel indicated that waivers might be executed by entering fewer days into the system than the animal was actually boarded. Another obstacle is the ongoing deficiency in tracking of existing registrations, citations and vaccinations. This deficiency was brought to ACADs attention in 2010 by the County Auditor and appears to be a continuing problem.

INTERVIEW SUMMARIES

As a part of the investigation, OIG Special Agents conducted numerous witness interviews. Significant interviews are summarized below:

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1. Specialist A

Specialist A was formerly employed by ACAD. She stated that she witnessed three separate incidents between the time periods of September 2012 to April 2013 in which other Specialists left their ELBs unlocked in their county trucks overnight. She further stated that she reported each incident to her supervisors but that ACAD took no disciplinary action against the Specialists. The first incident occurred on September 1, 2012, after she entered a county truck and noticed that there was an ELB on the floor under the passenger side seat. She opened the unlocked ELB and saw that it contained the controlled substances. She sent an email, to which she appended photographs of the controlled substances, but learned in May 2013 that ACAD took no disciplinary action in connection with the violation of the Handling SOP. (See photographs attached as Exhibit 4).

Specialist A stated that the second violation of the Handling SOP she observed occurred on or about March 23, 2013, when she observed an ELB wide open with controlled substances in plain view on the passenger side floor belonging to another officer that had the day off. She verbally reported violation to Mr. Cooper and showed him a photograph of the open ELB (Exhibit 5).

Specialist A stated that the third violation of the Handling SOP she observed occurred on April 11, 2013, when she again discovered an unlocked ELB in a truck she was taking out on duty. She did not photograph the ELB, but emailed Mr. Cooper, asking shall I bring it in? Mr. Cooper responded, Ill get it. Again, ACAD failed to take any disciplinary action in connection with the violation.

2. Specialist B

Specialist B stated that ACAD personnel were not properly storing the euthanasia and sedative drugs they were provided with in violation of the countys policies and DEA rules. He also stated that ACAD was returning animals back to their owners without having the mandatory rabies vaccinations performed. He further stated that ACAD was failing to collect county licensing fees and animal at-large citation fees prior to returning the animals to their owners.

Specialist B stated that he did not receive any specific training from ACAD regarding the proper storage of the controlled substances. He explained that each Specialist has to take a 40hour course offered by the Florida Animal Control Association and a second 16-hour course on euthanasia. Once a Specialist completes training, his supervisor directs the ACAD clinic to prepare an ELB for the Specialist, who must read and sign the Handling SOP before taking possession. The Handling SOP indicated that the drugs should be kept at all times under the two lock mechanism system and that the officers are responsible for the daily storage and use of the equipment issued to them. The SOP also indicated that all drug usage must be properly logged in the book provided to the Specialists. This should include the date, amount used, animal identification number of the animal patient and balance remaining after use. The Handling SOP also states that when the officer is off duty the euthanasia equipment must be placed in the ELB, locked, and then placed in the designated locker and padlocked.

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Specialist B advised that he was aware of the three separate incidents that Specialist A reported. He had also spoken to Mr. Cooper about them. Specifically, Mr. Cooper informed him that he had provided verbal counseling to the Specialists involved, and that no new problems had been reported since those incidents.

In June 2013, Specialist B submitted a complaint to Mr. Cruz wherein he alleged, among other things, that on at least three separate occasions he had informed Mr. Cooper that Specialists had failed to properly secure their ELBs, but that Mr. Cooper had taken no action. The complaint was forwarded to Human Resources, which undertook an investigation. Thereafter Human Resources issued a memorandum in which it concluded that when those instances had been brought to Mr. Coopers attention, he immediately verbally counseled the offending Specialists, and that since management was not aware of any reoccurrences of this concern, no further corrective action has been taken.

Specialist B stated that in September 2013, he twice observed that one of his colleagues had let an ELB overnight in a truck that he was taking out on his shift. He further stated the ELBs were placed in the bolted box in the truck, but the ELBs should have been stored in the lockers in the GCWB. He also stated that during the same time period, he saw a Specialist regularly leaving his truck after a shift and not taking the ELB into the GCWB.

Specialist B advised that once the controlled substances are depleted, a Specialist goes to the clinic and gets a new supply. The Specialist needs to show the veterinarian or veterinarian technician that their log books show zero amounts. He stated the Specialists are not required to turn in their empty vials. He also stated that ACADs Chameleon system is supposed to track the use of the drugs as well as the log books, but they are not compared when the Specialists come in for refills. In the opinion of Specialist B, the Chameleon system and the log books are not properly reconciled. He noted that his log book has never been audited or inspected by ACAD management or the veterinary staff, and he had no knowledge if any other audits or inspections have been done to reconcile the drug books to the Chameleon system. Instead, Specialist B observed, his colleagues and he are on the honor system.

Specialist B stated one of the problems with the Chameleon system is that there are two separate fields that indicate dose amounts and these fields are not defined in any manuals, so that Specialists can enter different dosages for sedative drugs and euthanasia drugs in the two fields. This creates an inherent problem for anyone attempting to reconcile the drug amounts, since data is not entered into the Chameleon system in a uniform manner.

Specialist B stated that in the spring of 2013, while working at the kennel and not in the field, he administered euthanasia drugs to an animal and noted the dosage amount on the animals kennel card, which is established for every animal admitted to the kennel. The kennel card provides the history of everything that happens to that animal while in custody to include any euthanasia drug amounts that were administered. Specialist B explained that as he was leaving for the day he informed the kennel supervisor that he did not have a chance to enter the dosage amount into the Chameleon system; the supervisor responded not to worry, as he had already

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done so. Specialist B asked how he knew the correct drug amount, and the supervisor replied that he had guessed.

Specialist B stated that in October 2011, Director Pierce created a new policy of returning animals back to their owners without having the mandatory rabies vaccinations performed, and not requiring payment of outstanding county licensing fees and animal at-large fees. He also stated that this policy is in direct violation of the county ordinances which state that all impounded animals will be provided with the rabies vaccinations prior to release, and that all violations or licensing fees will be paid prior to release. He further stated that Director Pierce wanted to make the agency more accepting to the public and wanted the kennel to be known as a happy place for the public and that enforcement is negative. Under the new policy, the kennel supervisors would return animals to owners without the required rabies vaccinations, and fees for the unlicensed animal and the at-large violations were waived prior to the release. The kennel supervisors were supposed to provide a log of these returned animals and their owners to the Specialists, who would then go out to the owners residences and provide 30-day warning notices to them advising that they had to get their animals vaccinated for rabies and to get the necessary licenses. The Specialist would then issue a citation for the at-large violation.

Specialist B stated that the new policy was worked by the kennel staff and the Specialists for the first few months, but thereafter the staff stopped making follow up visits to the owners, so that the county started losing out on all the fees. He stated that county ordinance requires that all impounded animals be administered rabies vaccinations prior to being returned to owners. He also stated that the fees for being unlicensed and the at-large fees are also required to be paid prior to release. Specialist B estimated that over 1,500 animals were released to their owners in 2012; that fee for the rabies vaccination is $9 per animal; the no license fee is $30; and in 2012, the at-large fee was $97 (but the current fee is $137). He estimated that the county may have lost over $200,000 in fees during 2012 alone.

Specialist B stated that on at least one occasion, ACAD had impounded an animal for a 10-day quarantine periodbecause it was believed to have bit someonebut released it to its owners without being vaccinated for rabies due to the new policy. He provided another example, wherein he had picked up a dog and had it impounded, and then picked it up again within seven days of its initial release to its owner. He stated that he did some further research and found this happened with three other animals; but that no follow up was made by ACAD and that in each instance no fees had been collected. He stated that after he raised his concerns about the new policy to Mr. Cooper in January 2013, Mr. Cooper admitted that ACAD had lost sight of the policy and needed to correct it.

Specialist B stated that he also repeatedly informed ACAD supervisors of his concerns about the failure of the Division to comply with county ordinances and policy. For example, in a March 10, 2013 email, he provided specific information regarding certain animals which he determined were released to their owners from the shelter without ACAD collecting licensing fees and at-large fees, including a rough estimate of the dollars amount of fees lost. For February 2013 alone, Specialist B reported that ACAD waived fees and citations for 69 of 77

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dogs released to their owners, at a minimum loss of over $8,000. He also raised the issue of lack of equitable treatment with regard to those owners who were required to pay: [h]ow would they feel if they knew so many didnt get fined? Specialist B concluded the email by stating I have questioned this multiple times and it has never gone anywhere. Please let me know who I need to speak with that can address this. As a taxpayer and employee, I do care about my employers revenue because ultimately, that affects my paycheck.

Specialist B stated that after his repeated complaints to management, ACAD directed Ms. Feser to take on the task of following up on the RTO citation list. He explained that she was supposed to print out all of the daily RTO sheets, make follow-up calls, and then place the follow-up calls on the schedule and enter them into the computer for the Specialists. He stated that this caused a back log for the Specialists, who were then required to deliver citations, and they became overwhelmed. Thereafter, instead of requiring the Specialists to travel to the owners home to write the 30-day warning letters and issue at-large citations, Ms. Feser just started sending out the citations via certified mail. Specialist B stated that he was aware of 160 citations that were sent out to the owners via certified mail. He further stated that was a problem because the owners were not signing for the certified mail and it was being returned, or the owners were no longer living at the address on record. He added that to his knowledge, ACADs release of animals back to their owners without administering rabies vaccinations, and failing to collect impound fees, license fees, and at-large citation fees is still ongoing.

Specialist B stated that in the summer of 2013, he was ordered to administer rabies vaccinations at a rabies clinic in Parkland. He further stated that the county promotes these rabies vaccination clinics and supplies Specialists to administer the injections. He also stated that this might violate Florida law, since only licensed veterinarians should be injecting animals with the rabies vaccinations. Specialist B stressed that he administered the injections only because he had been ordered to do so.

3. Interview of Specialist C

Specialist C recalled seeing the Handling SOP and attending a meeting where Dr. Johnston provided training on the new policy and distributed the ELBs, drugs, and other equipment. Specialist C stated that the policy required that after every shift the Specialists bring the ELBs into the GCWB and store them under lock and key in secured stationary lockers. He also stated that the only time a Specialist was not required to lock the ELB in a stationary locker was when he was assigned to the on-call shift. He further stated that it was an unspoken rule that the ELBs needed to be put into the secured locker after shifts end. However, he stated, he was told that as long as the ELB is locked up in the county truck then it was okay.

After having been informed by OIG Special Agents that they had watched him leave his county truck in the parking lot after his shift and not carry his ELB into the building, Specialist C admitted that he did not take his ELB up to his stationary locker every night, but rather would just leave it in his county truck. He also admitted that he sometimes put the ELB into the trunk of his personal vehicle. Specialist C stated that he knows this is a violation of the policy its

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on me. However, he stated that he has been bringing it up every night for the past few weeks.22 He also stated that for a very long time he had lost the key to the padlock for his secured locker. He stated that last week he advised Ms. Feser of this and he was then provided with a new padlock and was reminded of the policy. He admitted that he didnt want to bring the ELB up into the building and it was just pure laziness. Specialist C added that there are no daily sign-in sheets he is required to sign regarding storing his ELBs in its locker, and that the ACAD supervisors do not conduct inspections of the lockers to ensure that the ELBs are locked up every day.

Specialist C stated that after Specialist A complained that he had left his ELB in a county truck, he was not disciplined, but verbally counseled by Mr. Cooper. He further stated that Mr. Cooper did not cite the ELB policy or say it was a violation of the policy to leave the ELB in the truck, perhaps because Mr. Cooper knew that he was aware of the policy.

Specialist C stated that when he needed to refill his euthanasia and sedative drugs he took his drug log book to the clinic and would have his vials and bottles refilled by Dr. Johnston or a veterinarian technician. He also stated that he generally turns in his empty bottle and vial prior to receiving the new drugs. When he was given the new drugs it would start a new date and new amounts of the drugs that were provided t

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