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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Department of Homeland Security
Jacksonville State University Did Not Always Follow Procurement and Contracting Requirements
Jacksonville State University (Jacksonville State) did not always account for and expend Federal Emergency Management Agency (FEMA) grant funds according to Federal regulations and FEMA guidelines. Specifically, Jacksonville State did not fully comply with Federal regulations and FEMA guidelines to include federally required contract provisions in its disaster contracts. Jacksonville State’s exclusion of the required contract provisions exposed FEMA funding to unnecessary risks.
The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a congressional referral regarding the care of a patient who was admitted for alcohol withdrawal and later died at the Hampton VA Medical Center (facility) in Virginia.
The OIG identified failures in the management of alcohol withdrawal symptoms of this complex patient by nursing staff and providers. Nursing staff failed to accurately and timely assess the patient’s alcohol withdrawal symptoms and consistently administer medications in adherence with the facility’s Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) protocol used to determine the severity of the symptoms and clinical response. Additionally, the OIG found concerns with the timeliness of nursing staff’s electronic health records (EHR) documentation of CIWA-AR assessment scores. Delayed entries of assessment scores may affect providers’ clinical decisions. These failures may have affected the overall management of the patient’s alcohol withdrawal symptoms.
The OIG determined that facility providers failed to recognize the severity of the patient’s alcohol withdrawal. Based on past medical history and admissions, the patient was considered high risk for developing delirium, a severe form of alcohol withdrawal. According to clinical guidelines, delirium can be effectively treated with a benzodiazepine medication such as lorazepam. The OIG found one provider did not confirm the availability of lorazepam before making a clinical decision to use another medication that was not a benzodiazepine. Another provider documented symptoms suggestive of severe alcohol withdrawal but failed to identify several risk factors of severe withdrawal and treat the symptoms. These failures likely contributed to the patient not being afforded evidence-based care for prevention of delirium and severe alcohol withdrawal.
The OIG made seven recommendations to the Facility Director related to compliance with facility CIWA-AR protocol, CIWA assessment, and the management of severe alcohol withdrawal.
Audit of the Claims Processing and Payment Operations as Administered by Blue Cross and Blue Shield of South Carolina for Contract Years 2020 through 2022
Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the New York Office of Victim Services to Safe Horizon, Inc., New York, New York
Implementation Review of Corrective Action Plan: GSA’s Administration of Performance-Based Contracts Puts the Government at Risk of Unsatisfactory Contractor Performance and Wasted Funds, Report Number A210064/A/3/F23002, February 9, 2023
For our audit of the U.S. Census Bureau's 2020 Post-Enumeration Survey (PES) results, our objective was to assess the validity of those results as they related to overcounts and undercounts. We found that I. Operational disruptions and mitigations in response to missing data increased uncertainty in PES estimates; II. A smaller-than-anticipated sample size contributed to increased uncertainty in PES estimates; and III. The bureau did not carry out quality control processes for PES operations as planned.
