Federal Reports

To ensure the continued operations of the International Space Station and the safety of the crew, NASA and its spacesuit support contractor must ensure the suits used for spacewalks, designed more than 50 years ago, are well-maintained and reliable. The contractor, Collins Aerospace, has struggled to ensure sufficient life support components for the suits are delivered when needed and within budget and that meet quality expectations. While Collins’ performance over the last several years has declined, NASA has limited leverage to incentivize improved performance.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine whether leaders and staff followed required procedures related to suspected elder abuse of a community living center (CLC) resident at the St. Albans VA Medical Center in Queens, part of the VA New York Harbor Healthcare System (system). 

The OIG determined leaders and staff failed to follow procedures to report suspected abuse. A nursing assistant witnessed another nursing assistant allegedly abuse a resident but failed to immediately notify a supervisor, due to being “scared.” Nursing leaders and staff did not immediately ensure the resident’s safety, and did not report the suspected abuse to a unit social worker, VA Police, the resident’s family, and the New York State Department of Health. A nurse practitioner evaluated bruises on the resident and did not document a complete physical exam, consider whether the bruises were related to abuse, or inform the resident’s family. Staff described a culture of silence in the CLC in which staff generally did not report, or underreported, patient safety incidents due to fear of reprisal or administrative burdens. 

Leaders conducted two factfinding investigations into the alleged abuse; however, neither factfinding was thorough, which led to inaccurate conclusions. Factfinding 2 was completed approximately five months after the alleged abuse, exceeding a 14-day completion requirement. An accurate conclusion would have indicated the allegation of patient abuse was plausible and required system leaders to conduct an administrative investigation board. 

The OIG found additional reporting deficiencies related to other incidents of suspected resident abuse; insufficient staff training; substandard documentation by staff, which hindered reviews and investigations; and omissions in Veterans Health Administration and system abuse-related policies. 

The OIG made one recommendation to the Under Secretary for Health, who concurred in principle, and six recommendations to the System Director.
 

Under a contract monitored by this office, the Office of the Inspector General engaged Castro, an independent public accounting firm, to perform the Fiscal Year 2025 Independent Evaluation of the Smithsonian Institution’s Information Security Program. 
 

Smithsonian Enterprises (SE) oversees the majority of the revenue-generating operations of the Smithsonian Institution
(Smithsonian). It is an essential source of unrestricted funds— monies without donor-imposed or legal restrictions on their use. SE provides unrestricted funds to the Smithsonian through the operation of revenue-generating activities.
In SE's fiscal year (FY) 2023, SE generated $150.8 million in net revenue, including more than $63 million from 32 retail stores, approximately $10.7 million of which were cash transactions.

OIG made four recommendations for Smithsonian Enterprises management to improve compliance with policies and procedures related to document retention, audits over cash management, system access for separated employees, and discounts. Management concurred with all four recommendations.

The OIG received a hotline allegation that the Veterans Service Center manager at the Philadelphia VA Regional Benefit Office permitted a senior veterans service representative (VSR) to “blindly” approve hundreds of rating decisions for disability benefits claims each day without conducting the required reviews. The OIG team substantiated the allegation. From at least fiscal year 2022 through 2024, this senior VSR authorized about 85,300 claims—about 19 times the national average. The senior VSR spent an average of 4.7 minutes reviewing each claim authorized during this three-year period, versus a national average of about 21 minutes. The OIG obtained data showing that the senior VSR rarely opened necessary documents to verify claim information prior to authorization. The senior VSR contributed more than 35 percent each year toward the regional office’s claims completions goal, a metric that is part of regional office executive directors’ performance standards.

Based on the results of a statistical sample of 32 rating decisions that the senior VSR authorized from January 1, 2024, through June 30, 2024, the team estimated that approximately 13,200 decisions (84 percent) had at least one error. Some of the errors likely occurred because the senior VSR did not open and review the necessary documents. Monetary impact errors resulted in an estimated $2.2 million in improper payments during this period.

Officials from the regional office, the Northeast District, and the central office were aware of the Philadelphia senior VSR’s unusually high authorization rate. However, they overlooked opportunities to strengthen internal controls and effectively respond to the associated risks. The OIG recommended the under secretary for benefits review the errors the OIG team identified, correct these errors, and evaluate the effectiveness of controls for authorization rate outliers.