Federal Reports

The Department designed its review and approval processes to provide reasonable assurance that it would identify and resolve potential instances of State plans’ noncompliance with the ESEA and McKinney-Vento Act requirements subjected to peer review. The Department also designed the review and approval processes to provide reasonable assurance that it complied with selected ESEA and McKinney-Vento Actrequirements and Department policy. Although the Department implemented its plans for providing guidance to peer reviewers and States and implemented its peer review process in a manner that provided reasonable assurance of State plans’ compliance with ESEA and McKinney Vento Act requirements, we found that the Department did not implement all aspects of the review and approval processes as designed. The The Department did not (1) always retain records that ensured adequate and proper documentation of its peer reviewer selection decisions or its analysis of peer reviewer comments on the McKinney-Vento Act requirements of State plans, (2) publish all versions of States’ plans on its website, or (3) always show that it considered conflict of interest information collected from peer reviewers before assigning them to panels. We did not identify any evidence that would suggest that the Department acted outside its authority to disapprove a State plan as set forth in section 1111(a)(4)(A)(vi) of the ESEA. However, because of the issues noted above, we could not determine why the Department selected certain peer reviewers. We also could not always determine whether the Department considered the results of the peer review process whenproviding feedback on the McKinney-Vento Act section of State plans. Finally, we could not ensure that the Department considered conflict of interest information it collected from peer reviewers before assigning them to panels, which could affect the integrity of the peer review processes.

The Department designed policies and procedures for awarding and monitoring discretionary grants through its Discretionary Grant Handbook. Additionally, the Department designed risk mitigation strategies specific to the Defraying Costs and Emergency Assistance programs through the Internal Control Plan. Together, these policies and procedures, as designed, should have provided reasonable assurance that the Department awarded and monitored grantees’ uses of Defraying Costs and Emergency Assistance grants in accordance with the Bipartisan Budget Act, Uniform Guidance, and Department policy. We concluded that OPE did not implement all the relevant Discretionary GrantHandbook processes and Internal Control Plan risk mitigation strategies as designed. Specifically, OPE did not (1) scrutinize costs in all applications and eliminate those costs that were unallowable; (2)validate grantees’ self-reported data; (3) prepare appropriate terms, such as a high-risk designation and associated conditions, for any awards made to grantees it designated as high risk; (4) apply its Emergency Assistance program allocation formula as designed; (5)conduct post-award conferences; (6) complete post-award monitoring; (7) support changes made through administrative action grant award notifications; and(8) retain all relevant records in official Emergency Assistance grant files.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations related to the care provided to a patient who died at the Charlie Norwood VA Medical Center (facility) and an allegation that the facility director failed to ensure adequate psychiatric provider coverage. The OIG did not substantiate that the patient died due to overmedication, because the cause of death was bilateral pulmonary thromboemboli with prolonged restraint and “noncontributory” toxicology findings. However, the OIG identified deficiencies during the patient’s care that likely contributed to the patient’s death. Staff improperly ordered and initiated medical-surgical restraint for the patient. Given that the patient was restrained for approximately 71 hours, the staff’s failure to effectively address the patient’s deep vein thrombosis prophylaxis needs contributed to the patient’s death. Staff’s failure to address the patient’s nicotine dependence may have contributed to the worsening of the patient’s agitation that led to restraint usage. Facility leaders and staff failed to comply with Georgia State law involuntary commitment process requirements. The OIG substantiated that the lack of mental health provider involvement likely contributed to the patient’s death, and the patient endured an unnecessary four-hour ambulance trip in restraints that likely contributed to the development of pulmonary thromboemboli.The OIG substantiated that the facility’s Downtown Division lacked adequate psychiatric providers to manage mental health emergencies and that leaders failed to ensure a psychiatrist was included on their code gray team. Also, nurse practitioners had been cancelling outpatient appointments so they could respond to Downtown Division mental health consult requests. The OIG concluded that the Disruptive Behavior Committee failed to provide input that may have reduced the patient’s risk of violence throughout the patient’s care and may have contributed to the mismanagement of the patient’s mental health treatment needs. The OIG made 18 recommendations.