Federal Reports

An Amtrak Coach Cleaner based in Miami, Florida, was terminated from employment on October 5, 2023, following her administrative hearing. Our investigation found that the employee violated company policies by engaging in outside employment while on a medical leave of absence.

Poor contractor performance and technology development issues threaten to push NASA’s On-Orbit Servicing, Assembly, and Manufacturing 1 project (OSAM-1) beyond its $2.05 billion budget and projected December 2026 launch date.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Michael E. DeBakey VA Medical Center (facility) in Houston, Texas, to evaluate Veterans Integrated Service Network (VISN) and facility leaders’ response to critical surgical events from 2018 through 2021 and assess actions to prevent reoccurrence.The facility reported eight critical surgical events during this time frame—five wrong-site surgeries and three instances of retained surgical items. The OIG found that facility leaders took progressive actions including peer reviews, counseling, a focused professional practice evaluation (FPPE) for cause, and termination to address a provider responsible for three wrong-site surgeries. However, the OIG identified deficiencies with the implementation and quality of the FPPE for cause, and in reporting the provider to state licensing boards (SLBs) and the national practitioner data bank (NPDB).Facility leaders ensured a root cause analysis (RCA) was generated for each critical surgical event and that Surgery Service leaders implemented additional actions to improve processes. However, the OIG identified deficiencies with some RCAs related to timeliness and subsequent action plans. The OIG determined that three critical surgical events may have been prevented in the absence of the RCA deficiencies. Facility leaders and staff could not explain the reasons for the deficiencies in the RCAs.The OIG determined VISN leaders provided oversight and consultation to facility leaders regarding critical surgical events. VISN leaders provided consultation and recommendations to facility leaders for managing the provider, and conducted annual reviews of the facility’s RCA process, identified deficiencies, and alerted facility leaders to areas in need of improvement.The OIG made three recommendations to the Facility Director related to conducting and documenting FPPEs for cause, reporting providers to SLBs and the NPDB, and completing RCAs and subsequent action plans.

The SBIR and STTR Extension Act of 2022 reauthorized the Small Business Innovation Research (SBIR) and the Small Business Technology Transfer (STTR) programs. The Inspector General of a Federal agency that participates in the SBIR or STTR programs must submit an annual report to Congress describing its investigations involving those programs (15 U.S.C. Section 638b(c). Information in this report presents the OIG investigative information related to SBIR for FY 2023.

Legionnaires’ disease is caused by Legionella bacteria, found naturally in freshwater environments. The bacteria can become a health concern when spread through showerheads, faucets, ice machines, and hot water tanks in the water systems of large buildings. A 2017 CDC report concluded that one in every four people with healthcare associated Legionnaires’ disease dies.Veterans Health Administration (VHA) Directive 1061 establishes standards to prevent and control healthcare associated Legionnaires’ disease at VHA owned buildings where patients, residents, visitors, or staff stay overnight. The VA Office of Inspector General (OIG) audited whether VHA is complying with the directive and effectively addressing the prevention and control of Legionella for potable water distribution systems.The OIG determined that the four VA medical facilities reviewed—in Salem, Virginia; Brooklyn, New York; Pittsburgh, Pennsylvania, and Dublin, Georgia—did not fully comply with VHA requirements on components of their healthcare-associated Legionella disease prevention plans, water safety testing validation collection, remediation actions, and reporting practices. VHA leaders also did not receive complete water safety test results needed for effective oversight. Additionally, VA medical facility leaders responsible for notifying clinical staff of Legionella conditions did not communicate positive test results to staff to ensure awareness of elevated diagnostic levels. Specifically, the OIG found incomplete healthcare associated Legionella disease prevention plans; inconsistent water sampling; noncompliance with remediation actions; and inconsistent test result reporting.The OIG made eight recommendations to improve oversight of Legionella water sampling, fix identified problems, and ensure Directive 1061 is followed.