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 Bay Pines Healthcare System and eight outpatient clinics in Florida. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection 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; High-Risk Processes: Management of Disruptive and Violent Behavior.When the team conducted this inspection, the executive team had worked together for nine months. All staff were permanently assigned. Employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected and discrimination was not tolerated. However, responses also highlighted opportunities to reduce staff feelings of moral distress at work. Patient experience survey data implied satisfaction with the care provided. Further, the OIG found that selected survey results for female respondents were generally more favorable than those for female VHA patients nationally. The OIG identified an opportunity to strengthen the tracking of sentinel events that warrant institutional disclosure. Executive leaders were knowledgeable within their scope of responsibilities about selected VHA data used by the Strategic Analytics for Improvement and Learning models.The OIG issued five recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Disclosure of adverse events(2) Quality, Safety, and Value• Surgical work group processes(3) Mental Health• Suicide prevention training(4) High-Risk Processes• Disruptive behavior committee attendance• Patient notification

We determined that ICE did not always comply with segregation reporting requirements and did not ensure detention facilities complied with records retention requirements.

Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Commodity Futures Trading Commission FY2021

We conducted this engagement in coordination with the Pandemic Response Accountability Committee (PRAC) to gain an understanding of the U.S. Department of Housing and Urban Development’s (HUD) fraud risk management practices and develop an inventory of fraud risks that HUD had not already identified for the funds appropriated by the Coronavirus Aid, Relief, and Economic Security (CARES) Act for the Community Development Block Grant (CDBG) and Emergency Solutions Grant (ESG) programs.We identified five overall risk factors that contribute to the risk of fraud for the CDBG and ESG CARES Act funds.  We used these risk factors and the results of brainstorming sessions; interviews; and reviews of audit reports, investigations, and press releases to develop a fraud risk map containing 31 fraud schemes that can be used to misappropriate CDBG and ESG CARES Act funds.  We also identified opportunities to improve HUD’s fraud risk management practices, including clarifying roles and responsibilities, performing fraud-specific risk assessments, and raising awareness of fraud and fraud risks.We recommend that the Office of the Chief Financial Officer coordinate with Office of Community Planning and Development program staff to clarify the roles and responsibilities for fraud risk identification, assessment, and mitigation.  We recommend the Principal Deputy Assistant Secretary for Community Planning and Development 1) complete program-specific fraud risk assessments and risk profiles for the CDBG and ESG programs, 2) consider OIG’s fraud risk inventory to improve their fraud risk assessments, 3) implement efforts to increase the awareness of fraud at all levels, 4) develop and implement a fraud risk checklist or other instrument to be completed as part of each monitoring review, and 5) develop and implement a fraud analytics strategy using available data.