Federal Reports

The VA Office of Inspector General (OIG) conducted national surveys of Veterans Integrated Service Network (VISN) patient safety officers (PSO) and facility patient safety managers (PSM). Both surveys focused on patient safety topics, including oversight, culture, staffing, and training. The OIG also conducted interviews with Veterans Health Administration (VHA) Quality and Patient Safety leaders and PSOs.The OIG identified opportunities for VHA to strengthen patient safety programs at VISNs and facilities. Variability in PSO oversight related to site visit frequency and volume, and unclear expectations for PSO follow-up of facility patient safety program deficiencies, exist. PSOs reported barriers to meeting with community care third-party administrators to discuss quality and safety concerns. A majority of PSOs reported responsibilities for areas outside of the patient safety program while a high percentage of PSMs reported feelings of burnout. Facilities that have a PSM and additional staff achieved a higher level of compliance with completing patient safety requirements.Inclusion of an analysis of patient safety data within National Center for Patient Safety (NCPS) published quarterly reports would help staff drive improvement. Both PSOs and PSMs identified that patient safety is not always considered in decision making. Lastly, although PSO and PSM training is recommended, no formalized training requirements are available.The OIG made one recommendation to the VHA Under Secretary for Health related to evaluating PSO and PSM communication with community care third-party administrators and two recommendations to the VHA Assistant Under Secretary for Quality and Patient Safety related to establishing facility patient safety program oversight requirements and evaluating barriers that limit VISN and facility leaders’ engagement with PSOs and PSMs. The OIG made six recommendations to the VHA NCPS Executive Director related to evaluating quarterly reports, PSO and PSM burnout, patient safety program staffing, and implementing formalized training.

We have identified a concern regarding the inability of both OIG and Agency personnel to extract EPA SBIR contract data—such as information about proposals, bids, awards, contractors, and subcontractors—from the EPA Acquisition System in meaningful ways to allow for oversight through data analytics, queries, and other proactive initiatives.

The EPA should review unliquidated obligations for programs that received a substantial increase through the IIJA to ensure that the funds are used for the intended programs or deobligated timely to fund other environmental projects, as appropriate.

To see our report, click on the link below

For this audit, our objective was to determine if the U.S. Department of Commerce and its bureaus identify and remediate vulnerabilities on their high value IT assets (HVAs) in accordance with federal requirements. We found that while the Department conducts HVA assessments in accordance with federal requirements, it did not always effectively identify and remediate vulnerabilities. It also did not follow best practice security guidance for HVAs. As a result, I. HVAs are operating with significant risk due to unresolved vulnerabilities; and II. OIG successfully exploited security weaknesses on multiple HVAs. All seven of the HVAs in our review had at least one exploitable vulnerability type, and the Department’s vulnerability scanners do not always identify vulnerabilities in HVAs. We also learned during our audit that the U.S. Patent and Trademark Office (USPTO) had asked the Department to downgrade all of its HVAs to non-HVAs. In September 2023, the Department’s Chief Information Officer agreed to downgrade the majority of USPTO’s HVAs.

Audit of the USITC's Vehicle Fleet Program