Publicly Released: September 1, 2020
The objective of this audit was to determine whether the Military Departments properly accounted for and safeguarded pharmaceuticals at locations supporting overseas contingency operations in the U.S. Central Command (USCENTCOM) area of responsibility (AOR). In this audit, we visited eight medical treatment facilities (MTFs); four MTF medical logistics facilities; a U.S. Army Medical Materiel Center-Southwest Asia (USAMMC-SWA) warehouse; and three USAMMC-SWA Forward Logistics Elements (FLEs) located in Qatar, Kuwait, and Afghanistan.
The DoD operates a large network of MTFs to provide routine medical care to maintain healthy forces in the field and the specialized care for treating traumatic injuries and exotic diseases in combat. There are 44 MTFs in the USCENTCOM AOR that are considered “temporary” in nature. Within the USCENTCOM AOR, there are MTF medical logistics facilities to provide medical materiel management. Medical logistics facilities assist with the procurement, storage, and distribution of pharmaceuticals.
In addition, the USAMMC-SWA warehouse serves as the theater lead agent for medical materiel and pharmaceuticals in USCENTCOM, and is designated to serve as the medical logistics distribution point for all Military Departments in the USCENTCOM AOR. Furthermore, USAMMC‑SWA FLEs provide forward-deployed stocks closer to MTFs and MTF medical logistics facilities in order to provide fast and responsive delivery of pharmaceuticals.
Pharmaceuticals are divided into two categories— controlled and non-controlled pharmaceuticals. Controlled pharmaceuticals can cause physical and mental dependence; therefore, there are restrictions placed on dispensing the pharmaceuticals to reduce the potential for abuse. Non‑controlled pharmaceuticals include over-the-counter medications and medications that require prescriptions. MTFs receive, store, and dispense both categories of pharmaceuticals.
The Military Departments did not fully account for or safeguard pharmaceuticals at seven MTFs, four MTF medical logistics facilities, one USAMMC-SWA warehouse, and two USAMMC-SWA FLEs in the USCENTCOM AOR. Specifically:
• One MTF, one MTF medical logistics facility, and one USAMMC-SWA FLE did not properly account for controlled pharmaceuticals. For example, at the USAMMC-SWA FLE in Kuwait, personnel did not include 28,594 diazepam injectors on their accountability records. Diazepam, also known as Valium, is used to induce sleep and treat anxiety and seizures.
• Two MTFs, two MTF medical logistics facilities, and one USAMMC-SWA FLE did not properly conduct monthly Disinterested Officer (DIO) inventories for controlled pharmaceuticals. For example, Area Support Group‑Qatar Troop Medical Clinic personnel did not complete DIO inventories for 4 months out of a 12-month period from September 2018 to August 2019.
• Two MTF medical logistics facilities and one USAMMC‑SWA FLE did not verify that controlled pharmaceuticals were only provided to authorized medical personnel listed on Department of the Army (DA) Forms 1687. In addition, four MTFs and two MTF medical logistics facilities had incomplete or outdated DA Forms 1687.
• Four MTFs did not complete required inventories of non-controlled pharmaceuticals, and one additional MTF began conducting inventories after we announced our audit and intent to visit the MTF.
• Five MTFs and the USAMMC-SWA warehouse did not properly safeguard pharmaceuticals. For example, personnel from one MTF did not restrict access to the pharmacy. Specifically, they left the pharmacy door open and the safe door storing controlled pharmaceuticals unlocked
These deficiencies in accounting for and safeguarding pharmaceuticals occurred because USCENTCOM’s existing guidance did not provide a unifying method for U.S. military forces within the USCENTCOM AOR to account for and safeguard pharmaceuticals in accordance with theater, service, and unit-level specific processes. For example, USCENTCOM’s standard operating procedures did not include clear requirements for conducting DIO monthly inventories and securing pharmaceuticals. In addition, USCENTCOM did not provide sufficient oversight of accountability and safeguarding pharmaceuticals. Although USCENTCOM personnel conduct USCENTCOM Theater Pharmacist visits to MTFs to determine individual compliance with USCENTCOM’s standard operating procedures, the review checklist used during the site visits was generic, did not include key requirement areas, and did not provide detailed steps that would have enabled the reviewer to identify the deficiencies we identified throughout this report. For example, the review checklist did not include a review of the DA Forms 1687 for accuracy and completeness or verification that required inventories of non-controlled pharmaceuticals occurred.
As a result of the accountability and safeguarding deficiencies identified at the MTFs, MTF medical logistics facilities, USAMMC-SWA warehouse, and USAMMC-SWA FLEs, the controlled and non-controlled pharmaceuticals at these locations are susceptible to loss, theft, abuse, and diversion. Controlled pharmaceuticals are particularly vulnerable to diversion for illicit use. Non‑controlled pharmaceuticals, which are pilferable and sometimes expensive, may be used for recreational use. Improper use of these pharmaceuticals can degrade military operations and damage the lives, safety, and readiness of military personnel.
Without properly conducting inventories, USCENTCOM would not be able to determine whether losses occurred or determine the exact amount of losses of controlled and non-controlled pharmaceuticals at each MTF, MTF medical logistics facility, and USAMMC-SWA FLE.
Management Actions Taken During the Audit
During the audit and while on site, MTF, MTF medical logistics facility, and USAMMC-SWA FLE personnel initiated corrective actions, including documenting patient returns of controlled pharmaceuticals and expired controlled pharmaceuticals on their accountability records, and updating or completing their DA Forms 1687. USAMMC-SWA FLE Kuwait personnel added controlled pharmaceuticals on their accountability records, and the amounts were verified during the May 2020 DIO inventory. In addition, several security improvements have been completed or initiated since the audit team site visits.
We recommend that the USCENTCOM Theater Pharmacist coordinate with the USCENTCOM Surgeon to establish or update policies and procedures to clarify the requirements for DIOs and action officers when conducting DIO inventories, and include in the policy requirements for the minimum level of security required for controlled and non-controlled pharmaceuticals for deployed MTFs within the USCENTCOM AOR.
We recommend that the USCENTCOM Theater Pharmacist develop a tracking mechanism and follow up on any deficiencies identified to verify that DA Forms 1687 are completed and updated and that DIO inventories are completed monthly.
We recommend that the USCENTCOM Theater Pharmacist update the site visit review checklist to include requirements to verify that DA Forms 1687 are completed and updated, non-controlled pharmaceutical inventories are completed, security procedures are followed, and security deficiencies are addressed.
Management Actions and Our Response
The USCENTCOM Theater Pharmacist and USCENTCOM Surgeon updated USCENTCOM guidance to clarify the responsibilities of DIOs and action officers when conducting inventories, to clarify the requirements for completing non-controlled pharmaceutical inventories, and to include minimum security requirements for controlled and non-controlled pharmaceuticals for deployed MTFs within the USCENTCOM AOR. The updates address the specifics of the recommendation. Therefore, the recommendation is closed.
The USCENTCOM Theater Pharmacist created a tracking mechanism for verifying that DA Forms 1687 and DIO inventories were completed and up-to-date. Specifically, the USCENTCOM Theater Pharmacist created folders on the USCENTCOM shared drive for tracking DA Forms 1687 and DIO inventories. He also created a Microsoft Excel spreadsheet to track whether MTFs are completing the DIO inventories as required. The creation of databases for the DA Forms 1687 and DIO inventories and the use of an Excel spreadsheet to track whether documents are received address the specifics of the recommendation. Therefore, the recommendation is closed.
In addition, the USCENTCOM Theater Pharmacist updated the site review checklist to verify that DA Forms 1687, non-controlled pharmaceutical inventories, and physical security requirements are completed. The updated checklist adequately addresses the deficiencies we identified during the audit by adding requirements to verify key accountability and safeguarding requirements during USCENTCOM Theater Pharmacist site visits. The actions taken address the specifics of the recommendation; therefore, the recommendation is closed.
This report is the product of Proj. No. D2019-D000RJ-0179.000