Federal Reports

The PACT Act authorizes VA to deliver veterans’ health care and benefits associated with exposure to environmental hazards during military service. VA may use the Cost of War Toxic Exposures Fund (TEF) to ensure proper claims processing by the Veterans Benefits Administration (VBA) and the administration of health care for eligible veterans. Congress authorized an initial appropriation of $500 million to set up the TEF for fiscal years 2023 and 2024 and required that VA produce a spending plan detailing funding allocation; it later appropriated an additional $5 billion in TEF support through fiscal year 2027, which was not part of this examination.As requested by the VA Secretary, the VA Office of Inspector General (OIG) examined the initial TEF appropriation. This memorandum focused on funds allocated to VBA, the Office of Information and Technology (OIT), and the Veterans Health Administration (VHA). Among its allowable uses, VBA, OIT, and VHA planned for 2,400 full-time employees. VA submitted a required spend plan to Congress. Estimation methodologies explaining specifically how funds will be used had been completed only for VHA, with the remaining methodologies anticipated in December 2023 and February 2024. This memorandum was issued to draw VA leaders’ attention to identified weaknesses. These included that VBA and OIT had not yet provided methodologies to explain their plan estimates; some spending plans had to be amended to avoid violations of the Purpose Statute; and monthly spending reports contained minor calculation inaccuracies.The OIG commends the Office of Management for proactively seeking legal guidance from the Office of General Counsel to ensure TEF allocations are used in accordance with their authorized purposes. No specific recommendations were made, but the OIG requested being informed of any additional actions taken to ensure proper use of the TEF once VBA and OIT finalize their estimation methodologies.

We engaged with an independent public accounting (IPA) firm to audit DIA's FY 2023 financial statements. We evaluated the reliability of data supporting the financial statements, determined the reasonableness of the statements produced, and examined disclosures in accordance with applicable guidance.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the quality of care provided during a patient’s hospitalization, which ended with the patient’s death at the Lt. Col. Luke Weathers, Jr. VA Medical Center (facility) in Memphis, Tennessee. The OIG also evaluated facility leaders’ response to the patient’s care.A telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a blue alert, which may have affected the patient’s outcome. A charge nurse’s failure to assign a nurse to care for the patient or provide accurate nursing assignments to the telemetry technician may have also contributed to the delay. Additionally, an intensive care unit fellow did not document a response to a critical care consult and did not recall the patient, rendering the OIG unable to determine the clinical decision-making rationale.Facility leaders’ factfinding and root cause analysis reviews of the patient’s care were not thorough, which hindered identification of systemic and causal factors. Contributing factors included a nursing leader who did not issue an authorization letter to provide the factfinding investigator guidance on the focus of the review, and the root cause analysis team who did not interview some staff directly involved with the patient event, as required.The OIG made five recommendations to the Facility Director related to compliance with the cardiac telemetry monitoring policy, making and communicating nursing assignments, documenting critical care consults, conducting factfindings and root cause analyses, and consideration of another root cause analysis.