Federal Reports

The OIG investigated allegations that an FWS contractor falsely certified payments to the U.S. Fish and Wildlife Service (FWS) under a construction contract it held in the Southeast Region and that the contractor failed to pay a subcontractor for work performed.We found no evidence that the contractor falsely certified payments to the FWS or that it withheld payment to its subcontractor. We found that the subcontractor did not provide the contractor with timely and accurate support for its invoices and that there were legitimate delays in the contractor’s payments to the subcontractor. In an eventual settlement, the subcontractor acknowledged they had been paid in full for the work performed.

We found that inadequate controls resulted in non-compliance with agency policies and guidance from the Office of Management and Budget. To reduce the risk of fraudulent behavior and financial abuse, the agency needs to improve its policies and procedures, training, and oversight provided to the purchase card program. By not maintaining sufficient controls to assure compliance with Peace Corps and Federal requirements, the Peace Corps put itself at risk for fraudulent behavior and financial abuse. We found several weaknesses caused by insufficient controls: inadequate policies and procedures, lack of required training, inadequate oversight, and inadequate use of the available data analytic tools. This report makes six recommendations to help enhance controls over purchase card transactions.

Wisconsin made 1,654 capitation payments totaling $589,478 ($347,822 Federal share) on behalf of deceased beneficiaries. We confirmed that all beneficiaries associated with these capitation payments were deceased.

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The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning the care of a patient who underwent cardiac surgery in 2015 at the VA Ann Arbor Healthcare System in Michigan. The OIG was unable to substantiate that the patient received inappropriate care during cardiac surgery that ultimately led to death. A cardiopulmonary bypass (CPB) catheter that was inserted to divert blood flow from the heart became misplaced. The patient did not receive adequate blood flow to the brain during surgery and died six days later. The OIG was unable to determine how or when the CPB catheter became misplaced. Review of the electronic health record and interviews determined the placement of the catheter, initiation of CPB, and maintenance of CPB during most of the surgery appeared unremarkable. Misplacement of the CPB catheter was discovered towards the end of the procedure, when attempting to restore normal blood flow through the heart. In response to one of the three allegations, the OIG confirmed that the anesthesiologist was present for the critical points of the procedure and did not abandon the patient during surgery. The OIG reviewed the facility’s quality management processes including root cause analysis, peer review, and disclosure records. Not all required processes were completed. Additionally, the facility did not evaluate the modifications that the surgeon and anesthesiologist made in their practices after the patient’s surgery through a systemic quality review to determine if the modifications might be successful or improve patient care. The OIG made one recommendation to the Veterans Integrated Service Network Director related to the facility’s compliance with quality management processes requirements, and one recommendation to the facility Director related to the surgeon’s and anesthesiologist’s modifications in their practice.