Federal Reports

Seek link below for the full report, report summary, multimedia or any agency follow-up.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Carl Vinson VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Care; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results; and High-Risk Processes: Emergency Department/Urgent Care Center Operations. The facility’s leadership team was not stable, with vacancies for director and chief of staff. Employee satisfaction and patient experience surveys results were similar to or lower than VHA averages. The OIG’s review of institutional disclosures identified an opportunity to ensure timely notification to patients and accurately maintain information and data on disclosures. The leaders should continue to take actions to improve care and performance of measures contributing to the Strategic Analytics for Improvement and Learning “3-star” and community living center “1-star” quality ratings. The OIG issued 22 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary utilization management data reviews • Root cause analyses • Resuscitative episode reviews (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Privileging action reporting to National Practitioner Data Bank (3) Environment of Care • Panic alarm testing (4) Medication Management • Reconciliation of dispensing and return of stock • Verification of hard copy prescriptions • Monthly controlled substances inventory verification • Medication override process (5) Mental Health • Communication of issues, services, and initiatives to leadership • Military sexual trauma training (6) Geriatric Care • Patient/caregiver education and understanding of medications (7) Women’s Health • Designated women’s health medical director/clinical champion • Women Veterans Health Committee processes • Cervical cancer screening data tracking process • Patient notification of abnormal results (8) High-risk Processes • Backup call schedule for urgent care center providers

This is our final report on the audit of the National Oceanic and Atmospheric Administration (NOAA) Office of Marine and Aviation Operations (OMAO) ship fleet recapitalization effort. Our objective was to determine whether NOAA OMAO performed effective acquisition planning for its construction of new ships. Based on our review, we found that the initial acquisition planning for two Class A ships was not adequate.

This final memorandum addresses the results of our attempt to audit $5,030,452 that the Gulf States Marine Fisheries Commission (the Commission) paid to its subrecipient, the Gulf and South Atlantic Fisheries Foundation (GSAFF), under financial assistance award NA10NMF4770481 from the National Oceanic Atmospheric Administration (NOAA). Our audit report OIG-19-021-A includes the results of three other subrecipients’ claimed costs and other objectives audited under award NA10NMF4770481.

To fulfill our responsibilities under Chief Financial Officers Act of 1990 (CFO Act) (Pub. L. No. 101-576) and related legislation, we monitored Grant Thornton LLP's audit of the Social Security Administration's (SSA) Fiscal Year (FY) 2019 financial statements to ensure the quality of the audit work performed was adequate.

To summarize and assess the most serious management and performance challenges facing the Social Security Administration (SSA).

In compliance with the Reports Consolidation Act of 2000, the U.S. Department of Education (Department) Office of Inspector General reports annually on the most serious management and performance challenges faced by the Department. In addition to the challenges themselves, these reports include a brief assessment of the Department’s progress in addressing the challenges and identity further actions that, if properly implemented, could enhance the effectiveness of the Department’s programs and operations. For FY 2020, we identified four management challenges the Department faces as it continues its efforts to promote student achievement and preparation for globalcompetitiveness by fostering educational excellence and ensuring equal access. These challenges are (1) improper payments, (2) information technology security, (3) oversight and monitoring, and (4) data quality and reporting.

Skilled Nursing Facility (SNF) claims include Resource Utilization Groups (RUGs) that identify whether a beneficiary received therapy and the range of therapy minutes provided. For example, SNF claims with a RUG that begins with "RU" or "RV" indicate that an ultra high or very high level of therapy was provided and that during a 7 day period, the beneficiary received 720 minutes or more, or 500 to 719 minutes of therapy, respectively. The higher the volume of therapy services provided, the higher the Medicare payment.