Federal Reports

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the El Paso VA Health Care System, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s leadership team had been working together for nine months, and the chief of staff and associate director were the newest members of the leadership team and were appointed in April and August 2018, respectively. Selected survey scores related to employee satisfaction with the facility’s leaders and patient experience survey data revealed opportunities to improve both employee and patient satisfaction. The organizational risk factors detailed in this report did not identify any substantial risk in quality of care. The leadership team was knowledgeable within their scope of responsibility about selected SAIL metrics but should continue to take actions to sustain and improve performance measures contributing to the SAIL “1-star.” The OIG issued seven recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Annual inventory of resources and assets • Development and maintenance of an emergency operations plan (3) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications (5) Women’s Health • Women Veterans Health Committee reports to leaders

This report presents the results of the audit of Natural Resources Conservation Service’s (NRCS) financial statements for the fiscal year ending September 30, 2019. The report contains an unmodified opinion on the consolidated financial statements, as well as an assessment of NRCS’ internal controls over financial reporting and compliance with laws and regulations.

Semiannual Report to Congress: Covering April 1, 2019 - September 30, 2019

The Corporation for National and Community Service, Office of Inspector General (CNCS-OIG) presents its Fall 2019 Semiannual Report, covering the six-month period of April 1, 2019 – September 30, 2019.

The Department of Veterans Affairs, Office of Inspector General (OIG) issued the Semiannual Report to Congress (SAR) April 1 – September 30, 2019. The SAR summarizes the results of OIG oversight, provides statistical information, and lists all reports issued April 1 – September 30, 2019. During this reporting period, OIG audits, investigations, inspections, evaluations, and other reviews identified over $1.81 billion in monetary benefits for a return of $24 for every dollar invested in OIG oversight. Also during this reporting period, OIG issued 161 reports and publications on VA programs and operations, made 661 recommendations, and conducted investigations that led to 131 arrests.

The OIG investigated an allegation that a Bureau of Land Management (BLM) employee may have accessed and viewed child pornography on a Government computer on multiple occasions.We found that the employee accessed and viewed adult pornography on the Government computer while inside a Government office but found no evidence the employee viewed child pornography. The employee admitted viewing adult pornography on multiple occasions but denied any involvement with child pornography. Accessing and viewing pornography on a Government computer violates DOI policy; the employee said he knew that DOI policy prohibited his actions.The employee retired during our investigation.