Federal Reports

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The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Senator Joe Manchin to review the postoperative care of a patient (Patient) who had vascular surgery at the Martinsburg VA Medical Center (Facility), West Virginia. In general, the OIG found the Patient’s immediate postoperative care was proper. However, the OIG had concerns with the Patient’s management at the Community Based Outpatient Clinic (CBOC) 10 days after the procedure when the Patient presented with signs and symptoms of a known vascular procedure complication. After an endovascular aneurism repair (EVAR), the Patient’s clinical condition was consistent with cholesterol embolization syndrome which has no accepted specific therapy. On EVAR post-operative day (POD) 14, the Patient had amputations of three toes and was noted to have infection in the amputated bone. The OIG could not determine if earlier toe amputations would have prevented the bone infection. On POD 10, after determining the Patient was experiencing a medical emergency, CBOC patient aligned care team staff did not ensure coordination of the Patient’s subsequent care. Staff failed to facilitate a safe transition between the CBOC and a non-VA hospital equipped to treat the Patient. Staff did not communicate relevant information or provide health record information to providers at the non-VA hospital upon learning where the Patient planned to seek emergency treatment. The OIG found deficiencies in Veterans Health Administration policy compliance with the lack of policy or standard operating procedure on the management of health emergencies in the CBOC and inconsistent health record documentation for the Patient. The OIG made three recommendations related to coordination of care, health emergency management, and health record documentation.

We investigated allegations that a BIE official, when he was the principal of a BIE boarding school, had attempted to increase the school’s Federal funding by:• Allowing or directing the enrollment of students in the school’s gifted and talented (GT) program without properly assessing them• Submitting inaccurate student attendance recordsWe found that enrollment in the school’s GT program went up dramatically while the official was principal and that this increased the school’s Federal funding, but we did not find evidence that the official had directed school staff to identify GT students specifically to augment the school’s funding. We also learned that the school employees who oversaw the GT program after the BIE official left did not consistently comply with regulations governing GT programs at BIE schools that receive Federal funds.In addition, we found that most of the school’s students were absent as many as 6 days before the end of the school year when traveling from the school to their homes, but when the official was principal he directed school employees to mark them present in the attendance records. We did not find that this practice directly affected school funding, but it did reduce the students’ available instructional time.We provided this report to the Principal Deputy Assistant Secretary – Indian Affairs for any action deemed appropriate.

The VA Office of Inspector General (OIG) audited the Veteran Health Administration’s (VHA’s) Program of Comprehensive Assistance for Family Caregivers from June 2017 through June 2018 to determine if VHA effectively provided program services to qualified veterans and their caregivers. The Family Caregiver Program pays a monthly stipend to caregivers of eligible veterans. The OIG found that veterans and their caregivers did not receive consistent access to the program. The OIG found that caregiver support coordinators (CSCs) did not determine eligibility within the required 45 days for about 65 percent of the 1,822 veterans approved for the program from January through September 2017. The OIG also found that VHA did not correctly apply eligibility criteria when enrolling veterans. Four percent of the 1,604 veterans discharged from the program from January through September 2017 were never eligible. As a result, VHA made about $4.8 million in improper payments to their caregivers. VHA also did not consistently monitor and document the health statuses of an estimated 50 percent of the veterans discharged during the same period. The OIG found clinicians and CSCs either did not adequately document the extent that veterans’ health conditions changed or they failed to routinely monitor veterans and their caregivers before the reassessment leading to their program discharge. VHA failed to manage the Family Caregiver Program effectively because it did not establish governance that promoted accountability for program management. Also, VHA did not establish a staffing model to ensure medical facilities were well equipped to manage the program’s workload. The OIG recommended designating additional program oversight, applying program criteria to ensure eligibility determinations are accurate, ensuring veteran applications are processed within the 45-day standard, consistently monitoring and documenting veterans’ health statuses, and establishing guidelines for when a veteran’s need for care changes.

What We Looked AtWe reviewed the State of Rhode Island and Providence Plantations' single audit report for the fiscal year ending June 30, 2017, in order to identify findings that affect directly awarded Department of Transportation programs. An independent auditor prepared the single audit report, dated March 28, 2018.What We FoundWe found that the report contained a special tests and provisions requirements finding that needs prompt action from the Federal Highway Administration's (FHWA) management.RecommendationsWe recommend that FHWA ensures that the State complies with the special tests and provisions requirements. We also recommend that FHWA recovers $214,516 from the State, if applicable.

What We Looked AtWe reviewed the North Coast Railroad Authority's single audit report for the fiscal year ending June 30, 2017, in order to identify findings that affect directly awarded Department of Transportation programs. An independent auditor prepared the single audit report, dated March 27, 2018.What We FoundWe found that the report contained a reporting requirements finding that needs prompt action from the Office of the Secretary's (OST) management.RecommendationsWe recommend that OST ensures that the North Coast Railroad Authority complies with the reporting requirements.