Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection addressing confidential allegations of a patient’s delays in renal cancer care and lack of care coordination at the Cheyenne VA Medical Center (Cheyenne), Wyoming, and the Iowa City VA Health Care System (Iowa City), Iowa. The OIG substantiated that Cheyenne clinicians failed to provide timely and proper surveillance (follow-up) for the patient’s renal cell carcinoma and left nephrectomy (kidney) surgery. Contributing factors included a lack of clear communication among providers through electronic health record documentation, inaccurate diagnostic coding on the patient’s problem list, and limited patient evaluations. Additionally, an institutional disclosure and peer reviews were not initiated. The OIG did not substantiate that Iowa City providers failed to provide care and were unaware of the patient’s cancer history. Although Iowa City providers documented the patient’s history of a left nephrectomy, an e-consult to Urology Service for further evaluation was not addressed timely and resulted in a delay in care. Additionally, the OIG found issues with the providers’ problem list documentation and peer reviews were not initiated for the patient’s care. The OIG reviewed additional Iowa City patients’ electronic health records to determine if those urology consults were timely and found that clinical care was provided and patients were not negatively impacted. However, Urology Clinic providers did not always complete e-consult documentation as required by Veterans Health Administration policy. The OIG made five recommendations to the Cheyenne Director related to timely surveillance for cancer patients, care coordination and communication between Cheyenne providers and non-VA providers for cancer patients, problem lists documentation, and initiation of institutional disclosure and peer reviews for the patient’s care. The OIG made two recommendations to the Iowa City Director related to documentation of patients’ problem lists and initiation of peer reviews for the patient’s care.

The overall assessment of the Commission’s information security program was deemed effective because of the ratings throughout the IG Federal Information Security Modernization Act of 2014 (FISMA) Reporting Metrics domain. Due to the success demonstrated by the Commission’s compliance with FISMA, there are no new recommendations in this report. We found the Commission made significant progress to develop, document, and implement agency-wide information security measures that support its operations. The Commission improved ITsecurity and completed most actions needed from prior year recommendations.

Performance Audit of RRB's Compliance with the Federal Information Security Modernization Act of 2014 Fiscal Year 2018

Management Information Report: Limited Oversight of the National Railroad Retirement Investment Trust Puts Railroad Retirement Assets at Risk

As a follow-up to our 2017 report on TSA’s Federal Air Marshal Service’s (FAMS) domestic flight operations, we conducted this audit to determine the extent to which FAMS can interdict an improvised explosive device during flight. We identified vulnerabilities with FAMS’ contribution to international flight security. Details related to FAMS operations and flight coverage presented in the report are classified or designated as Sensitive Security Information. We made two recommendations.