USCIS' Medical Admissibility Screening Process Needs Improvement, Office of Inspector General, 2018
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USCIS’ Medical Admissibility Screening Process Needs Improvement September 21, 2018 OIG-18-78 DHS OIG HIGHLIGHTS USCIS’ Medical Admissibility Screening Process Needs Improvement September 21, 2018 Why We Did This Audit USCIS is responsible for verifying that foreign nationals applying for lawful permanent resident status meet health-related standards for admissibility. We performed this audit to determine whether USCIS has controls in place to ensure it complies with these standards. What We Recommend We made eight recommendations that, when implemented, will improve USCIS’ selection and oversight of physicians and its review of foreign nationals’ medical forms. What We Found U.S. Citizenship and Immigration Services (USCIS) has inadequate controls for verifying that foreign nationals seeking lawful permanent residence status meet health-related standards for admissibility. First, USCIS is not properly vetting the physicians it designates to conduct required medical examinations of these foreign nationals, and it has designated physicians with a history of patient abuse or a criminal record. This is occurring because USCIS does not have policies to ensure only suitable physicians are designated. Second, when reviewing these foreign nationals’ required medical forms, USCIS Immigration Services Officers, are accepting incomplete and inaccurate forms because they are not adequately trained and because USCIS does not enforce its existing policies. As a result of these deficiencies, USCIS may be placing foreign nationals at risk of abuse by physicians performing medical examinations. USCIS could also be exposing the U.S. population to contagious or dangerous health conditions from foreign nationals erroneously granted lawful permanent resident status. USCIS Response USCIS concurred with the eight recommendations and described corrective action to implement them. We consider seven of the recommendations resolved, and one recommendation is unresolved pending USCIS reconsidering options for corrective action that were discussed after the draft report was issued. All recommendations remain open. For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at DHS-OIG.OfficePublicAffairs@oig.dhs.gov www.oig.dhs.gov OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Washington, DC 20528 / www.oig.dhs.gov September 21, 2018 MEMORANDUM FOR: The Honorable L. Francis Cissna Director U.S. Citizenship and Immigration Services FROM: John V. Kelly Senior Official Performing the Duties of the Inspector General SUBJECT: USCIS’ Medical Admissibility Screening Process Needs Improvement Attached for your action is our final report, USCIS’ Medical Admissibility Screening Process Needs Improvement. We incorporated the formal comments from the U.S. Citizenship and Immigration Services in the final report. The report contains eight recommendations aimed at improving USCIS’ selection and oversight of physicians and its review of foreign nationals’ medical forms. Your office concurred with the eight recommendations and described corrective actions to implement them. Based on information provided in your response to the draft report, we consider recommendation 4 open and unresolved. As prescribed by the Department of Homeland Security Directive 077-01, Follow-Up and Resolutions for the Office of Inspector General Report Recommendations, within 90 days of the date of this memorandum, please provide our office with a written response that includes your (1) agreement or disagreement, (2) corrective action plan, and (3) target completion date for each recommendation. Also, please include responsible parties and any other supporting documentation necessary to inform us about the current status of the recommendation. Until your response is received and evaluated, the recommendation will be considered open and unresolved. Based on information provided in your response to the draft report, we consider recommendations 1 through 3 and 5 through 8 open and resolved. Once your office has fully implemented the recommendations, please submit a formal closeout letter to us within 30 days so that we may close the recommendations. The memorandum should be accompanied by evidence of completion of agreed-upon corrective actions and of the disposition of any monetary amounts. OFFICE OF INSPECTOR GENERAL Department of Homeland Security Please send your response or closure request to OIGAuditsFollowup@oig.dhs.gov. Consistent with our responsibility under the Inspector General Act, we will provide copies of our report to congressional committees with oversight and appropriation responsibility over the Department of Homeland Security. We will post the report on our website for public dissemination. Please call me with any questions, or your staff may contact Sondra McCauley, Acting Assistant Inspector General for Audits, at (202) 981-6000. Attachment OFFICE OF INSPECTOR GENERAL Department of Homeland Security Table of Contents Background .................................................................................................... 1 Results of Audit .............................................................................................. 4 USCIS Does Not Properly Vet Physicians It Designates as Civil Surgeons ................................................................................ 4 USCIS’ Review of Medical Forms Is Inadequate .................................... 11 Recommendations ....................................................................................... 14 Management Comments and OIG Analysis................................................... 16 Appendixes Appendix A: Objective, Scope, and Methodology .................................. 20 Appendix B: USCIS Comments to the Draft Report .............................. 23 Appendix C: Office of Audits Major Contributors to This Report ........... 28 Appendix D: Report Distribution .......................................................... 29 Abbreviations A-files CDC CFR HHS INA ISO LEIE MQRR NPDB NPWR OIG U.S.C. USCIS www.oig.dhs.gov Alien files Centers for Disease Control and Prevention Code of Federal Regulations Health and Human Services Immigration and Nationality Act Immigration Services Officer List of Excluded Individuals and Entities Medical Quality and Risk Reduction National Practitioner Data Bank National Processing Workflow Repository Office of Inspector General United States Code U.S. Citizenship and Immigration Services OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Background U.S. Citizenship and Immigration Services (USCIS) administers the Nation’s lawful immigration system, safeguarding its integrity and promise by efficiently and fairly adjudicating requests for immigration benefits while protecting Americans, securing the homeland, and honoring our values. As part of its mission, USCIS reviews and adjudicates the applications of foreign nationals who legally enter the United States and want to adjust from a temporary status to a lawful permanent resident status. USCIS has the authority to determine a foreign national’s admissibility to the United States; according to the Immigration and Nationality Act (INA), immigrants who seek to adjust their status may be inadmissible based on health-related grounds, which are designed to protect the health of the U.S. population.1 When applying for adjustment of status, foreign nationals are required to undergo a medical examination by a physician whom USCIS has designated as a civil surgeon. Physicians apply to USCIS for designation as civil surgeons by submitting an Application for Civil Surgeon Designation (Form I-910). Civil surgeons do not determine a foreign national’s admissibility or eligibility for immigration status adjustment; they perform the required medical examination and report the findings on a Report of Medical Examination and Vaccination Record (Form I-693) (medical form). The civil surgeon provides the sealed, completed medical form to the applicant, who then provides it to USCIS. Prior to March 11, 2014, individual USCIS field offices were responsible for determining whether a physician met the requirements to be designated as a civil surgeon. When the program was centralized in March 2014, USCIS “grandfathered” more than 4,200 civil surgeons, thereby allowing them to maintain their designation without completing a Form I-910 for further verification. Since March 11, 2014, Immigration Services Officers (ISO) at USCIS’ National Benefits Center review and adjudicate Forms I-910. 1 8 United States Code (U.S.C.) § 1182(a)(1) www.oig.dhs.gov 1 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Figure 1 shows USCIS’ process for designating physicians as civil surgeons. Figure 1. USCIS’ Process for Designating Civil Surgeons, as of March 11, 2014 Source: Department of Homeland Security Office of Inspector General (OIG) representation of USCIS data Foreign nationals who legally enter the United States may apply to adjust to lawful permanent resident status by submitting an Application to Register Permanent Residence or Adjust Status (Form I-485) to USCIS. ISOs at USCIS field offices and service centers review and adjudicate applications for status adjustment. ISOs make the status adjustment determination after reviewing the application (Form I-485) and supporting documents, including the civil surgeon’s report on the medical form. ISOs review the medical form to determine whether the foreign national meets the health-related standards for admissibility. The medical form should contain the results of the civil surgeon’s medical examination and documentation of any health concerns that may make the foreign national inadmissible. According to the INA, the following four medical conditions may make a foreign national inadmissible on health related grounds: www.oig.dhs.gov 2 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security • communicable diseases of public health significance (e.g., gonorrhea, leprosy, and tuberculosis); • failure to show proof of required vaccinations (e.g., polio, varicella, and hepatitis A and B); • physical or mental disorders with associated harmful behavior as defined in the Diagnostic and Statistical Manual of Mental Disorders; and • drug abuse or addiction. Figure 2 shows USCIS’ medical form review process, which is used to verify the medical admissibility of foreign nationals seeking to adjust to lawful permanent resident status. Figure 2. USCIS’ Medical Form Review Process Source: DHS OIG representation of USCIS data www.oig.dhs.gov 3 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security In this report, we examine USCIS’ process for designating physicians as civil surgeons and USCIS’ review of the medical forms of foreign nationals applying to adjust to lawful permanent resident status. Results of Audit USCIS has inadequate controls for verifying that foreign nationals seeking lawful permanent residence status meet health-related standards for admissibility. First, USCIS is not properly vetting the physicians it designates as civil surgeons. We determined that USCIS designated physicians with a history of patient abuse or a criminal record as civil surgeons. This is occurring because USCIS does not have adequate policies to ensure only suitable physicians are designated as civil surgeons. Second, when reviewing these foreign nationals’ required medical forms, ISOs are accepting incomplete and inaccurate forms because they are not adequately trained and because USCIS is not enforcing its existing policies. As a result of these deficiencies, USCIS may be placing foreign nationals at risk of abuse by some civil surgeons. USCIS could also be exposing the U.S. population to contagious or dangerous health conditions from foreign nationals erroneously granted lawful permanent resident status. USCIS Does Not Properly Vet Physicians It Designates as Civil Surgeons In vetting physicians who apply to become civil surgeons, USCIS neither ensures the physicians meet eligibility requirements for designation as civil surgeons, nor has it prevented physicians with a history of patient abuse or criminal records from being designated as civil surgeons. In addition, USCIS allowed physicians to remain civil surgeons without verifying that they met eligibility requirements, and it does not always promptly revoke the designation of noncompliant civil surgeons. These deficiencies occurred because USCIS lacks policies and procedures to ensure civil surgeons meet and maintain professional requirements. As a result, USCIS could be risking the health and safety of foreign nationals applying for lawful permanent residence. USCIS Does Not Ensure Physicians Meet Civil Surgeon Eligibility Requirements The INA gives USCIS the authority to designate civil surgeons to conduct medical examinations of foreign nationals seeking immigration benefits, and the Code of Federal Regulations (CFR)2 provides general requirements for determining civil surgeon eligibility. According to the INA and the CFR, only licensed physicians with at least 4 years of professional experience may be 2 8 C.F.R. § 232.2 (2017). www.oig.dhs.gov 4 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security designated as civil surgeons. The USCIS Policy Manual (policy manual) provides more specific requirements for determining civil surgeon eligibility.3 According to the policy manual, an application for civil surgeon designation must contain: a completed Form I-910; proof of U.S. citizenship, legal status, or authorization to work in the United States; a copy of the physician’s medical degree verifying he or she is a Doctor of Medicine or Doctor of Osteopathy; a copy of the physician’s current full and unrestricted medical license in the state in which he or she seeks to perform immigration medical examinations; and evidence to verify the requisite professional experience, such as letters of employment verification. USCIS ISOs do not ensure that the physicians’ applications they review comply with requirements in the INA, CFR, and the policy manual. Specifically, we statistically sampled and reviewed 135 I-910 files of civil surgeons approved by USCIS between March 11, 2014, and June 30, 2017. For 19 of these 135 files (14 percent), USCIS did not have the evidence to prove a physician met the qualifications for a civil surgeon, with several of the 19 files missing more than 1 piece of evidence. Table 1 shows the evidence missing from the approved civil surgeons’ files. Table 1. Evidence Missing from 19 I-910 Files of Approved Civil Surgeons Number of Files with Evidence Missing* Type of Evidence Missing from File Required sections on the I-910 Form completed Proof of authorization to work in the United States Copy of the physician’s medical degree Copy of the physician’s medical license Evidence of requisite (4 years) professional experience 5 2 6 1 9 Source: DHS OIG analysis of reviewed I-910 files *The number of files adds up to more than 19 because some files were missing more than 1 type of evidence. Based on the results of our statistical sample, approximately 14 percent of the 1,337 civil surgeon designations, or an estimated 188 designations of the civil surgeon designation population, made between March 11, 2014, and June 30, 2017, may lack evidence to support USCIS’ decision to designate the physician as a civil surgeon. 3 USCIS Policy Manual, Volume 8, Part C, Chapter 2, Section B www.oig.dhs.gov 5 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security These I-910 review process deficiencies occurred because USCIS does not provide formal training to ISOs responsible for adjudicating civil surgeon applications and does not require second-level reviews. According to USCIS officials, one reason they do not provide formal training is that only 1 or 2 ISOs are assigned to review about 50 civil surgeon applications a month. USCIS Designates Civil Surgeons Who May Put Foreign Nationals’ Health and Safety at Risk In addition to designating physicians who may not meet eligibility requirements, USCIS failed to prevent physicians with a history of patient abuse or a criminal record from being designated as civil surgeons. We attribute this failure to inadequate reviews of physicians’ histories. Specifically, USCIS does not require ISOs to consider medical board disciplinary history before designating physicians as civil surgeons. Of USCIS’ 5,569 active civil surgeons, 132 could pose a health or safety risk to foreign nationals seeking to adjust their status.4 We identified 11 civil surgeons, active as of June 30, 2017, who had been excluded by the Department of Health and Human Services (HHS) OIG from participating in federally funded health care programs for various offenses. These 11 physicians were on HHS OIG’s List of Excluded Individuals and Entities (LEIE), a public list of individuals and entities excluded from participation in Medicare, Medicaid, and all other Federal health care programs. Although USCIS’ civil surgeons are not part of a federally funded health care program, they are the only physicians USCIS authorizes to conduct immigration-related medical examinations and to complete medical forms. As shown in table 2, these 11 physicians’ offenses ranged from convictions related to fraud, patient abuse, and neglect to exclusion or suspension from health care programs. Table 2. Offenses of Physicians Excluded from Federally Funded Health Care Programs Number of Civil Surgeons Categories of Excludable Offenses Conviction relating to program or health care fraud Default on health education loan or scholarship Federal or state health care program exclusion or suspension Patient abuse or neglect conviction Program-related conviction Total number of civil surgeons excluded from federally funded health care programs 1 2 4 1 3 11 Source: DHS OIG analysis of LEIE as of July 2017 and active civil surgeons as of June 30, 2017 4 There were 5,569 total active civil surgeons as of June 30, 2017. www.oig.dhs.gov 6 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Additionally, state medical boards have disciplined 121 active civil surgeons for offenses that may meet HHS OIG’s criteria for exclusion. Twenty-nine of the 121 civil surgeons had disciplinary actions for egregious infractions. These offenses include felony conviction for solicitation of capital murder and engaging in dishonest, gross, and repeated negligent conduct in patient care and treatment. Although some disciplinary conduct may have occurred years ago, the nature of the offense may continue to render these physicians a risk to those applying for immigration benefits. For example, USCIS designated the following physicians as civil surgeons: A physician in Georgia with a felony conviction for solicitation of capital murder because he attempted to hire a hit man to kill a dissatisfied patient in Houston, Texas. The California, Pennsylvania, and Texas Medical Boards subsequently revoked his license for the criminal conviction. However, the Georgia Medical Board allowed the physician to resume his practice several years later. A physician with a history of professional sexual misconduct and exploitation of female patients from a position of power, authority, and trust. The Texas Medical Board restricted his license for 5 years and the physician was not allowed to be alone with female patients while conducting physical examinations. A physician disciplined by the California Medical Board for numerous offenses, including allowing her medical assistants to dilute mumps, measles, rubella, and varicella vaccines; pre-draw vaccines; administer injections with less than effective needles; give free vaccines to ineligible patients; falsify medical records; and other unprofessional behaviors. Although Federal laws and regulations give USCIS discretion in designating physicians as civil surgeons, the component has established only minimal eligibility requirements for physicians. When they are determining whether to designate a physician as a civil surgeon, USCIS does not require ISOs to consider a physician’s medical board disciplinary history. Rather, USCIS officials said ISOs only check the status of the medical license the physician provided in the application. To guard against risking the health and safety of these foreign nationals, USCIS should more thoroughly scrutinize physicians before allowing them to become civil surgeons. DHS has a resource USCIS could use to better monitor physicians who apply for designation as civil surgeons. The Medical Quality and Risk Reduction Branch (MQRR) in DHS’ Workforce Health and Safety Division is responsible for protecting national security and mitigating liability by ensuring employees, detailees, and contractors have the qualifications and other credentials (e.g., licenses) necessary to perform medical services for, or on behalf of, DHS. www.oig.dhs.gov 7 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security MQRR uses the National Practitioner Data Bank (NPDB) to verify and continuously monitor medical provider credentials, including qualifications, licensure information, and other relevant health care provider data.5 Figure 3 shows the type of information captured in the NPDB. Figure 3. Types of Information in the National Practitioner Data Bank Source: https://www.npdb.hrsa.gov/resources/whatIsTheNPDB.jsp (last visited May 30, 2018) USCIS could use MQRR’s access to the NPDB to assess the suitability of physicians who apply to become civil surgeons. MQRR could notify USCIS of 5 Congress created the NPDB as an information clearinghouse, with the primary goals of improving health care quality, protecting the public, and reducing health care fraud and abuse in the United States. www.oig.dhs.gov 8 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security physicians who may not meet DHS suitability standards and may pose a risk to foreign nationals or national security. USCIS Allowed Civil Surgeons to Maintain Their Designation without Verifying Their Eligibility Prior to March 11, 2014, USCIS field offices designated physicians as civil surgeons. In March 2014, USCIS centralized the civil surgeon program and introduced the I-910 process, at which time the component “grandfathered” more than 4,200 civil surgeons, thereby allowing them to maintain their designation without verifying they met eligibility requirements.6 According to USCIS officials, these civil surgeons were not required to complete a Form I-910. Our review of 25 active grandfathered civil surgeon files showed that USCIS did not have the evidence necessary to support their designations. Specifically, USCIS did not have a file to support the designation of 4 of the grandfathered civil surgeons, and all 21 of the remaining civil surgeon files were missing 1 or more types of evidence required by the policy manual.7 Table 3 shows the evidence missing to support the grandfathered civil surgeon designations. Table 3. Evidence Missing from 25 Grandfathered Civil Surgeon Designations Number of Files with evidence missing* Type of Evidence Missing Proof of authorization to work in the United States Copy of the physician’s medical degree Copy of the physician’s medical license Evidence of requisite professional experience Entire file missing 10 17 3 21 4 Source: DHS OIG analysis of reviewed grandfathered civil surgeon files *The number of files adds up to more than 25 because some files were missing more than 1 type of evidence. This deficiency occurred because, prior to March 11, 2014, when field offices were designating physicians as civil surgeons, USCIS did not have formal policies requiring evidence to support their designation. Also, when the designation process was centralized, USCIS officials stated they did not ask the more than 4,200 grandfathered civil surgeons to provide evidence verifying they met the eligibility requirements. 6 We did not include USCIS’ decision to grandfather civil surgeons designated prior to the initiation of the I-910 process in the scope of this audit and take no position on the legality or propriety of USCIS’ decision. 7 USCIS Policy Manual, Volume 8, Part C, Chapter 2, Section B www.oig.dhs.gov 9 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security USCIS Did Not Take Prompt Action against Civil Surgeons Who Failed to Maintain a Current and Unrestricted Medical License Revoking a physician’s designation as a civil surgeon makes him or her ineligible to conduct immigration-related medical examinations. According to the policy manual and Form I-910 instructions, USCIS may revoke a civil surgeon’s designation for several reasons, including failure to: maintain a currently valid and unrestricted license to practice as a physician in any state in which the physician conducts immigration-related medical examinations; comply with Centers for Disease Control and Prevention (CDC) Technical Instructions for Panel Physicians and Civil Surgeons (technical instructions);8 and continue to meet the professional qualifications required for civil surgeon designation, engaging in immigration fraud, or otherwise engaging in activity that poses a risk to public health or safety. According to USCIS regulations, a form's instructions are incorporated into the regulations requiring its submission [8 CFR §103.2(a)(1)]. In reviewing a report that USCIS received in May 2017 on active civil surgeons, we identified 48 civil surgeons, who were not in our statistical sample and whose medical license was either expired or restricted. Although USCIS received the report in May 2017, several months elapsed before the component revoked the designations of 37 of the 48 civil surgeons. For the 37 civil surgeons, USCIS revoked 1 designation in July 2017, 34 designations in August 2017, and 1 designation in November 2017.9 As of December 2017, the other remaining 11 civil surgeons were active and able to conduct medical examinations while USCIS reviewed their medical license status. USCIS did not promptly revoke these designations because its process for identifying civil surgeons with inactive or restricted medical licenses is inefficient. According to USCIS officials, to determine whether civil surgeons should maintain their designation, USCIS checks the status of their medical license using a contractor, Evercheck, which is only required to verify medical license information on active civil surgeons biannually (every 6 months). Further, one ISO is responsible for manually reviewing Evercheck’s biannual report and determining whether a civil surgeon’s medical license is compliant. According to USCIS officials, the review requires considerable effort and time CDC’s Technical Instructions for Panel Physicians and Civil Surgeons are on the CDC website and include instructions on recording findings from the medical examination and on vaccinations, medical history, and communicable diseases. (See https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil surgeons.html, (last visited June 15, 2018). 9 One civil surgeon voluntarily relinquished the designation in August 2017. 8 www.oig.dhs.gov 10 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security because the biannual report contains medical license information for more than 5,500 civil surgeons. In addition to using the NPDB to monitor physicians applying to become civil surgeons (as noted previously), the NPDB may be another resource to monitor civil surgeons’ medical licenses. MQRR could notify USCIS of negative actions against civil surgeons’ medical licenses reported in NPDB, and this information could facilitate USCIS’ revocations. USCIS’ Review of Medical Forms Is Inadequate As part of adjudicating applications to adjust to lawful permanent resident status, ISOs review medical forms to verify foreign nationals meet healthrelated standards for admissibility. We reviewed 151 statistically sampled Alien files (A-files)10 of foreign nationals whom USCIS had approved for lawful permanent resident status. We identified errors in 44 of the medical forms in these A-files. Some errors were caused by ISOs accepting incomplete and inaccurate medical forms. In other cases, the forms were completed and signed, but ISOs did not verify that the civil surgeon who signed the form was active. Finally, in some instances, civil surgeons did not follow CDC’s technical instructions.11 These deficiencies occurred because USCIS did not adequately train ISOs on proper review of medical forms and USCIS did not enforce its existing policy, which requires ISOs to return inaccurate medical forms to the foreign national for corrective action. Also, USCIS does not review and track errors on medical forms to monitor how well civil surgeons comply with CDC’s technical instructions. As a result, USCIS cannot be certain the civil surgeons actually administered all required tests and vaccinations and may have granted lawful permanent residence status to medically inadmissible foreign nationals who could pose a health risk to the U.S. population. ISOs Accepted Incomplete and Inaccurate Medical Forms When adjudicating foreign nationals’ status adjustment applications, ISOs are required to determine a foreign national’s medical admissibility based on the information in the medical form. According to USCIS policy, when determining medical admissibility, ISOs must ensure medical forms are legible, complete, valid, signed and dated, and placed in a sealed envelope. If these requirements are not met, ISOs must return the medical form to the foreign national for A-files are the official files for immigration and naturalization records created or consolidated for non-U.S. citizens. 11 We attributed some of the same errors on medical forms to two or even three causes. For example, an ISO may have accepted an incomplete or inaccurate form, in which the civil surgeon also failed to follow CDC’s technical instructions. For this reason, the number of errors we identified exceeds the number of medical forms. 10 www.oig.dhs.gov 11 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security corrective action.12 ISOs may suspend their decision on the adjustment of status until a complete and accurate medical form is resubmitted. Also according to the policy manual, ISOs may grant a waiver for certain vaccinations, for example, if the foreign national has had a severe allergic reaction to a vaccination. In 32 of 151 A-files reviewed, ISOs did not comply with USCIS policy when reviewing medical forms and accepted incomplete or inaccurate medical forms. We identified the following errors: 19 medical forms missing vaccination information or in which the civil surgeon marked the wrong box on the vaccination portion of the form. 5 medical forms missing required medical tests, such as tests for gonorrhea or syphilis. 7 medical forms with various errors, such as the form was not signed by an active civil surgeon, the form had expired (requiring a new form), the civil surgeon signed the form before receiving test results, the civil surgeon did not verify the foreign national’s identity, or the form did not contain the required stamp from a health department. 1 medical form in which the civil surgeon’s information was not legible. Based on our statistical sample results, from October 2013 through May 2017, USCIS may have approved about 330,000 of 1,558,031 adjustment of status applications population with inaccurate or incomplete medical forms. These errors may have rendered the foreign nationals medically inadmissible. This acceptance of invalid medical forms occurred because USCIS does not adequately train ISOs on reviewing medical forms to determine whether the foreign national meets health-related standards for admissibility. When hired, USCIS provides new ISOs with fewer than 2 hours of training focused on health-related admissibility standards or on reviewing medical forms — out of 200 total training hours. For ISOs reviewing applications that do not require an in-person interview, USCIS provides up to 5 hours of total training focused on health-related admissibility standards. USCIS also did not maintain a record to demonstrate how often such training occurs and does not have a system in place to ensure ISOs receive annual training. ISOs Did Not Verify That Active Civil Surgeons Completed Medical Forms USCIS policy requires foreign nationals’ medical forms be signed and dated by an active civil surgeon who conducted the medical examination, but does not 12 USCIS Policy Manual, Volume 8, Part B, Chapter 4 www.oig.dhs.gov 12 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security require ISOs to verify the civil surgeon’s signature or whether the civil surgeon was active at the time of the examination. The policy manual13 only states that an ISO “should consult” the Find a Doctor tool on USCIS’ website14 to determine whether the physician is a designated civil surgeon. For 11 of the 151 A-files we reviewed USCIS could not demonstrate that an active civil surgeon completed the form. In these 11 A-files, either the civil surgeon’s signature on the medical form did not match USCIS’ records or the civil surgeon was not in USCIS’ internal system of civil surgeon information, the National Processing Workflow Repository (NPWR). Based on our statistical sample results, nearly 110,000 of 1,558,031 population of A-files approved from October 2013 through May 2017 may have similar errors. Rather than consulting Find a Doctor, ISOs could use NPWR to validate a civil surgeon’s status and signature when reviewing medical forms. Find a Doctor contains the civil surgeon’s office information, but it does not contain images of signatures or the dates a physician has been an active civil surgeon. NPWR contains more information on civil surgeons, such as status and designation date, signature,15 and, if applicable, periods of inactivity. However, USCIS does not require ISOs to use NPWR. As of October 2017, only 658 of 6,226 ISOs had access to the system. USCIS officials said ISOs who do not have access to NPWR rely on their familiarity with civil surgeons in their geographic location and on Find a Doctor. However, neither method allows ISOs to fully substantiate a civil surgeon’s information or verify that active civil surgeons are signing and dating medical forms. USCIS has advertised NPWR’s usefulness to several USCIS field offices and suggested ISOs request access. Civil Surgeons Did Not Follow CDC’s Technical Instructions Civil surgeons must follow CDC’s technical instructions for conducting medical examinations and filling out medical forms; failure to comply with the instructions is grounds for revoking civil surgeon designation. USCIS is not reviewing and tracking errors on medical forms to monitor civil surgeons’ compliance with the technical instructions. This occurred because Federal regulations do not specify that USCIS monitor and oversee civil surgeons. Consequently, civil surgeons may not receive proper instruction. USCIS also cannot effectively seek revocation of civil surgeons who fail to accurately complete medical forms or determine whether civil surgeons are administering required vaccinations and tests. USCIS Policy Manual, Volume 8, Part B, Chapter 4. The Find a Doctor tool is on the USCIS website at https://my.uscis.gov/findadoctor (last visited June 15, 2018). Foreign nationals may use this tool to locate a civil surgeon. 15 NPWR does not contain images of every civil surgeon’s signature. 13 14 www.oig.dhs.gov 13 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Of the 151 A-files reviewed, 28 contained medical forms in which the civil surgeon did not follow CDC’s technical instructions for completing the form. These errors included no evidence of testing the foreign national for gonorrhea and missing or incorrectly marked vaccinations. As stated previously, ISOs accepted medical forms with this missing or inaccurate information. Some of the missing information could indicate civil surgeons did not administer required tests and vaccinations, which may mean some foreign nationals did not meet health-related standards for admissibility. For example, according to the CDC, having gonorrhea is grounds for inadmissibility. In addition, the CDC’s Vaccination Technical Instructions for Civil Surgeons require civil surgeons, among other things, to administer required vaccines, such as those for polio, hepatitis B, varicella, and influenza, to those applying for status adjustment. Based on our statistical sample results, nearly 289,000 of the population of 1,558,031 A-files approved from October 2013 through May 2017 may have similar errors. According to the Government Accountability Office, management should establish and operate activities to monitor its internal control system and evaluate the results,16 but USCIS has done neither. According to USCIS, it is not responsible for monitoring civil surgeons. USCIS officials also informed us that the component does not have a process to monitor civil surgeons’ compliance with CDC technical instructions for completing immigration-related medical forms, even though failure to comply with these instructions is grounds for revoking USCIS designation as a civil surgeon. Recommendations Recommendation 1: We recommend the USCIS Chief of the Regulatory Coordination Division for the Office of Policy and Strategy develop stricter ineligibility requirements for civil surgeon designations, which could include standards used by the Department of Health and Human Services Office of Inspector General, and implement processes to strengthen the vetting process of physicians and active civil surgeons. Recommendation 2: We recommend the Associate Director for the Field Operations Directorate: a. establish a training regimen for personnel responsible for adjudicating civil surgeon applications; and b. establish quality control reviews of civil surgeon application decisions. 16 Principle 16 of Government Accountability Office Standards for Internal Control in the Federal Government www.oig.dhs.gov 14 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Recommendation 3: We recommend the Associate Director for the Field Operations Directorate review grandfathered civil surgeons to confirm that they meet current eligibility requirements, and that USCIS maintain all required documents. At a minimum, the eligibility requirements should include: a. prompt review and identification of noncompliant civil surgeons; b. issuance of Intent to Revoke notices within 30 days of identification; and c. re-evaluation of active civil surgeons to determine whether they meet the newly developed requirements. Recommendation 4: We recommend the Associate Director for the Field Operations Directorate evaluate the Medical Quality and Risk Reduction Branch services and implement applicable services to assist USCIS in making its civil surgeon determinations. Recommendation 5: We recommend the Director for USCIS strengthen its training program on health admissibility by: a. providing focused training on what the USCIS Policy Manual considers a complete and accurate medical form; and b. developing a schedule for recurrent training for Immigration Services Officers, at least annually. Recommendation 6: We recommend the Associate Director for Field Operations Directorate establish a quality control process to ensure that Immigration Services Officers only accept complete and accurate medical forms, as required by written policy. Recommendation 7: We recommend the Office of Policy and Strategy update the USCIS Policy Manual so Immigration Services Officers are required to verify the authenticity of the civil surgeon’s information, such as signature and designation status, on the medical form. Recommendation 8: We recommend the Associate Director for Field Operations Directorate establish a process to track civil surgeon medical form errors to identify areas that need improvement. The process should include: a. tracking civil surgeons’ accuracy in complying with CDC’s Technical Instructions for Panel Physicians and Civil Surgeons; b. tracking the completeness of the forms; and c. establishing a system to ensure civil surgeons understand and follow the CDC’s Technical Instructions for Panel Physicians and Civil Surgeons and to ensure civil surgeons who fail to fulfill their responsibilities face prompt revocation. www.oig.dhs.gov 15 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Management Comments and OIG Analysis USCIS concurred with our eight recommendations. We included a copy of the USCIS management comments in their entirety in appendix B. We also received technical comments to the draft report and made revisions to the report as appropriate. We consider seven recommendations to be resolved and open until USCIS implements the proposed corrective actions. Recommendation 4 is unresolved pending USCIS evaluating implementation options presented after the draft was issued. A summary of USCIS’ response and our analysis follows. USCIS Response to Recommendation #1: Concur. USCIS agreed that stricter eligibility requirements for civil surgeon designation and a strengthened vetting process will improve the quality and integrity of the program. USCIS’ Office of Policy and Strategy will lead a working group to evaluate current requirements and pursue regulatory amendments that would establish additional requirements that would enhance the program’s integrity. The group will also examine the feasibility of establishing an audit process to assess how well civil surgeons are complying with USCIS requirements and Technical Instructions for conducting the medical exam. USCIS anticipates completing actions to implement this recommendation by December 31, 2019. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation after we evaluate the results of the working group and verify USCIS has implemented stricter eligibility requirements and strengthened the vetting process. USCIS Response to Recommendation #2: Concur. The Director stated that USCIS’ Field Operations Directorate personnel are in the process of finalizing training materials for personnel responsible for adjudicating civil surgeon applications. USCIS will also establish a quality assurance program that will include a 100 percent review of newly trained officer’s work. USCIS anticipates completing actions to implement this recommendation by March 31, 2019. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation after we review the revised training materials and evaluate the effectiveness of the quality assurance program. USCIS Response to Recommendation #3: Concur. USCIS plans to implement a 100 percent review of active grandfathered civil surgeon records to confirm they meet eligibility requirements. If deficiencies are discovered, USCIS will issue a Request of Evidence and/or Notice of Intent to Revoke to resolve the deficiency. To the extent feasible, USCIS will issue the Notice of Intent to Revoke within 30 days of identification of a noncompliant civil surgeon. USCIS www.oig.dhs.gov 16 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security anticipates completing actions to implement this recommendation by March 31, 2019. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation after we review USCIS’ documentation supporting the review of the grandfathered civil surgeons. USCIS Response to Recommendation #4: Concur. The Director stated that USCIS completed an evaluation of the MQRR Branch services and determined that MQRR is not equipped to provide the services USCIS requires in making its civil surgeon determinations. Specifically, the Director stated that the NPDB does not validate medical licenses; MQRR can input only 10 physicians per day; and MQRR can only add or remove physicians on a quarterly basis. Based on these actions, the Director requested that the OIG consider this recommendation resolved and closed as implemented. OIG Analysis: We consider these actions nonresponsive to the recommendation, and they will remain unresolved and open. In follow-on discussions between the OIG and MQRR officials, we learned that MQRR is willing to work with USCIS to implement a batch submission process for 1,000 physicians at a time, which would drastically reduce the turnaround time. Further, MQRR officials confirmed they add and remove medical providers from the NPDB daily, and perform random credentialing records review to assess the accuracy of the information on a quarterly basis. MQRR did acknowledge that the NPDB does not validate medical licenses, but stated the NPDB does collect negative actions on a provider’s license. MQRR has committed to researching and reviewing medical credentialing software to automate the state licensure verification and the NPDB monitoring process. OIG shared this information with USCIS after reviewing management’s technical comments to the draft report. USCIS has since agreed to reconsider MQRR’s options. USCIS has committed to providing an updated response within 90 days from the issuance of the final report. USCIS Response to Recommendation #5: Concur. The Director committed to USCIS strengthening its training program on health admissibility through a series of actions. Multiple USCIS directorates and offices will work together to determine if training on the medical form during the ISO Basic Training Program can be enhanced. If it is determined that a more focused medical form training (i.e., increased training time) is feasible, USCIS would develop, review, and implement new training materials. USCIS will also work to develop an electronic training course on the medical form that new officers would be required to take after completing the Basic Training. This training would be available in the Department’s Performance and Learning Management System and could also be utilized as refresher training for officers, as needed. Once www.oig.dhs.gov 17 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security developed, the electronic medical form training course would be made available to all officers and required annually for those officers working on benefit types that require familiarity with health admissibility. USCIS anticipates completing actions to implement this recommendation by March 30, 2020. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation after we review USCIS’ documentation supporting the new training material and course. USCIS Response to Recommendation #6: Concur. USCIS agrees that a quality control process for the medical forms will assist them in accepting only complete and accurate medical forms. USCIS will establish a quality control review process for the medical forms to ensure compliance with written USCIS policy. USCIS will regularly review its written policies on medical forms to ensure that they comply with current CDC Technical Instructions. USCIS anticipates completing actions to implement this recommendation by September 30, 2019. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation after we review USCIS’ quality control process. USCIS Response to Recommendation #7: Concur. The Director stated that USCIS’ Office of Policy and Strategy, together with other USCIS directorates, will examine the feasibility of requiring officers to verify the authenticity of the civil surgeon’s information in the record, including comparing signatures of civil surgeons with their exemplar signatures contained in USCIS records, as well as other information relating to a civil surgeon. If deemed feasible, the Office of Policy and Strategy will revise the Policy Manual, as appropriate. USCIS anticipates completing actions to implement this recommendation by December 31, 2019. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. However, we recommend USCIS take all necessary steps to implement a process requiring an officer to follow policy ensuring foreign nationals’ medical forms be signed and dated by an active civil surgeon. We will close this recommendation after we review USCIS’ documentation on the feasibility study and subsequent changes to the policy manual. USCIS Response to Recommendation #8: Concur. USCIS states it is committed to developing and implementing a process that tracks medical errors as well as being able to identify areas of improvement. The creation of this process may entail the development of new technology, which supports such tracking. In the interim, officers may use the National Benefit Center’s Civil Surgeons mailbox to report non-compliant civil surgeons. USCIS will www.oig.dhs.gov 18 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security consult with the Office of the Chief Counsel regarding revocation of a civil surgeon who is failing to fulfill his or her responsibilities. In addition, USCIS plans to aggregate the overall I-693 errors and consult with the CDC on the best way to communicate with civil surgeons so that it can ensure physicians understand and follow the Technical Instructions, as well as the consequences of not doing so. USCIS anticipates completing actions to implement this recommendation by September 30, 2019. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation after we review USCIS’ proposed process and the results of any discussions with CDC. www.oig.dhs.gov 19 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix A Objective, Scope, and Methodology DHS OIG was established by the Homeland Security Act of 2002 (Public Law 107−296) by amendment to the Inspector General Act of 1978. We performed this audit to determine whether USCIS has controls in place to ensure foreign nationals meet health-related standards for admissibility prior to granting lawful permanent resident status. The scope of the audit includes a review of USCIS’ roles, policies, and standard operating procedures. The scope period for this audit was from October 2013 through June 2017. To achieve our objective, we reviewed Federal and component guidance on health-related standards for inadmissibility. We interviewed officials from DHS offices — Citizenship and Immigration Ombudsman, Civil Rights and Civil Liberties, and MQRR Branch; and USCIS offices — Customer Service and Public Engagement, Field Operations Directorate, Fraud Detection National Security, National Benefits Center, Office of Chief Counsel, Office of Policy and Strategy, and Service Center Operations Directorate. The team also interviewed officials from the U.S. Department of State and CDC to gain an understanding of the similarities or differences between the medical examination process within the United States and the medical examination process in foreign countries. We performed site visits to the Texas Service Center in Dallas, Texas; and the National Benefits Center in Lee’s Summit, Missouri, to gain an understanding of USCIS’ review process for medical examination forms related to adjustment of status and the civil surgeon application review process. We performed a limited review of the internal controls associated with USCIS’ medical screening process. Specifically, we evaluated USCIS compliance with Form I-910 applications and Form I-693 medical forms and compared them to USCIS policies and procedures. The findings identified in this report can be adequately addressed by implementation of our recommendations. In making these recommendations, OIG acknowledges that to the extent we recommend new policies, USCIS may be required to conduct formal rulemakings pursuant to the Administrative Procedures Act, 5 U.S.C. §551 et seq., applicable regulations, and judicial precedents. www.oig.dhs.gov 20 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix A (cont.) We performed a review to determine whether any civil surgeon active as of June 30, 2017, appeared on HHS OIG’s LEIE. Furthermore, we compared whether disciplinary actions for active civil surgeons notated on Evercheck’s May 2017 report would meet the LEIE criteria for exclusion if that surgeon participated in a federally funded health care program. We retrieved medical board orders and administrative hearing documents from the appropriate state medical board websites. Sampling Methodology The team selected three samples: I-910 civil surgeon applicants, grandfathered civil surgeons, and A-files. The civil surgeon and the A-file data was retrieved from the Standard Management Analysis Reporting Tool. Prior to selecting our samples, we tested the reliability of component-generated data during fieldwork on the Tool. We determined the information was sufficiently reliable to support the audit’s conclusions. Each sample selection was performed as follows: I-910 Civil Surgeons — As of June 30, 2017, there were 1,337 active civil surgeons who had completed the I-910 application. Assuming a population proportion of 50 percent, with the population size of 1,337 active civil surgeons, the minimum sample size required for a 95 percent confidence level and allowable error of ± 8 percent is 135. This sample of 135 I-910 application files was randomly selected with the help of IDEA software. To test for compliance with USCIS civil surgeon professional requirements, we used the sample results of these 135 I-910 files of active civil surgeons to infer it to the population of 1,337 active civil surgeons. Grandfathered Civil Surgeons — Our audit population was the number of grandfathered civil surgeons who had active designations as of June 30, 2017. At that time, USCIS had 4,232 grandfathered civil surgeons. The team performed a random sample to assess the level of documentation for professional requirements contained in the file. We selected a judgmental sample size of 25 grandfathered civil surgeons. We did not infer the results of this sample and only reported on the 25 files reviewed. Alien files — Our audit population was limited to A-files stored at the National Records Center, retired or archived, that contained an approved application to adjust status and a medical form adjudicated from October 1, 2013, through May 31, 2017. We did not include active A-files, even if they had adjusted status during our scope period, to minimize disruptions to USCIS business, such as being used for another USCIS process or a court case. The audit population consisted of 1,558,031 A-files containing an approved medical form www.oig.dhs.gov 21 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix A (cont.) and adjudicated between October 1, 2013, and May 31, 2017. Assuming a population proportion of 50 percent, with the population size of 1,558,031 A-files, the minimum sample size required for a 95 percent confidence level and allowable error of ± 8 percent is 151. This sample of 151 A-files was randomly selected with the help of Excel software. To determine whether ISOs reviewed and processed the medical forms according to USCIS policy, we used the sample results of these 151 A-files to infer it to the population of 1,558,031 A-files. This performance audit was conducted between February 2017 and March 2018 pursuant to the Inspector General Act of 1978, as amended, and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based upon our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based upon our audit objectives. www.oig.dhs.gov 22 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix B USCIS Comments to the Draft Report www.oig.dhs.gov 23 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 24 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 25 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 26 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 27 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix C Office of Audits Major Contributors to This Report Yesi Starinsky, Director Loretta Atkinson, Audit Manager Christine Alvarez, Auditor in Charge Julian Brown, Auditor Victoria Buono, Program Analyst Jennifer Eads, Program Analyst Mary Nowak, Auditor Juan Santana, Auditor M. Faizul Islam, Ph.D. Statistician Kevin Dolloson, Communications Analyst Kelly Herberger, Supervisory Communications and Policy Analyst Gary Alvino, Independent Reference Reviewer Brad Mosher, Independent Reference Reviewer www.oig.dhs.gov 28 OIG-18-78 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix D Report Distribution Department of Homeland Security Secretary Deputy Secretary Chief of Staff General Counsel Executive Secretary Director, GAO/OIG Liaison Office Assistant Secretary for Office of Policy Assistant Secretary for Office of Public Affairs Assistant Secretary for Office of Legislative Affairs USCIS Component Liaison Office of Management and Budget Chief, Homeland Security Branch DHS OIG Budget Examiner Congress Congressional Oversight and Appropriations Committees www.oig.dhs.gov 29 OIG-18-78 Additional Information and Copies To view this and any of our other reports, please visit our website at: www.oig.dhs.gov. For further information or questions, please contact Office of Inspector General Public Affairs at: DHS-OIG.OfficePublicAffairs@oig.dhs.gov. Follow us on Twitter at: @dhsoig. OIG Hotline To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click on the red "Hotline" tab. If you cannot access our website, call our hotline at (800) 323-8603, fax our hotline at (202) 254-4297, or write to us at: Department of Homeland Security Office of Inspector General, Mail Stop 0305 Attention: Hotline 245 Murray Drive, SW Washington, DC 20528-0305
