Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Eastern Colorado Health Care System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The system’s executive leadership team appeared stable and had worked together for over a year at the time of the OIG review. The system was recruiting for a new associate director position, and the Associate Director for Patient Care Services had been detailed to another role since March 2020. Employee survey data revealed opportunities for leaders to improve workplace satisfaction. Patients appeared satisfied with inpatient care, although the OIG noted opportunities to improve patient-centered medical home and specialty care. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued seven recommendations for improvement in four areas:(1) Quality, Safety, and Value• Quality management committee participation• Surgical work group attendance(2) Mental Health• Suicide prevention training(3) Care Coordination• Inter-facility transfer policy• Patient transfer monitoring and evaluation• Medical record transmission(4) High-Risk Processes• Disruptive behavior training

The U.S. Postal Service considers mail to be delayed when it is not processed in time to meet the established delivery day or when it is processed but not on the dock in time for scheduled transportation to delivery units. Delayed mail can adversely affect Postal Service customers and harm the organization’s brand.The Postal Service launched the new Mail Condition Visualization (MCV) system in January 2019. The system provides near real-time visibility of a facility’s on-hand volume, delayed processing volume, delayed dispatch volume, and oldest mail date by mail category and processing operation; and stores historical trailer information.

OIG reviewed FNS’ controls over the SNAP Online Purchasing Pilot in response to the COVID 19 pandemic.

The objective of our ongoing inspection is to evaluate FNS’ oversight of TEFAP—this report provides interim results on whether FNS identified risks related to the safeand efficient distribution of USDA-food assistance to States during the COVID-19pandemic.

Since our FY 2020 evaluation, the Office of Intelligence and Analysis (I&A) has continued to provide effective oversight of the department-wide intelligence system and has implemented programs to monitor ongoing security practices. We determined that DHS' information security program for Top Secret/Sensitive Compartmented Information intelligence systems is effective this year as the Department achieved “Level 4 – Managed and Measurable” in three of five cybersecurity functions, based on current reporting instructions for intelligence systems. However, we identified deficiencies in DHS’ protect and recover functions. We made three recommendations to I&A to address the deficiencies identified, and I&A concurred with all three recommendations.

We identified deficiencies in E-Verify’s processes for confirming identity during employment verification. E-Verify’s photo matching process is not fully automated, but rather, relies on employers to confirm individuals’ identities by manually reviewing photos. We attribute these deficiencies to USCIS not developing or evaluating the plans and internal controls needed to improve its processes and detect, track, and investigate system errors. Until USCIS addresses E-Verify’s deficiencies, it cannot ensure the system provides accurate employment eligibility results. We made 10 recommendations to improve E-Verify’s accuracy, internal controls, and workload capabilities. USCIS concurred with all 10 recommendations.