Federal Reports

The VA Office of Inspector General conducted a healthcare inspection at the Hampton VA Medical Center (facility) in Virginia to assess allegations related to the delay in diagnosis and treatment of a patient with a newly found lung mass.The OIG substantiated that there was a delay in diagnosis and treatment for a patient with a new lung mass, highly suspicious for cancer. The OIG found multiple care coordination deficiencies in scheduling and communication that led to the delay. As the patient likely had metastatic disease at initial presentation, the OIG could not determine if the delay in care coordination contributed to the patient’s death.The OIG determined the facility did not have an operational cancer committee, tumor board, or a certified cancer registrar at the time of the inspection. The lack of administrative oversight, and programmatic development, directly impacts the quality of patient cancer care. The lack of the programs did not contribute to the patient’s death, but may have impacted the quality of oncology services provided by the facility.The OIG determined that the facility submitted a Joint Patient Safety Report after being notified of the OIG inspection. Although a root cause analysis was conducted, the facility failed to identify care coordination deficiencies, such as scheduling delays, as contributing factors to the patient’s death. An institutional disclosure was conducted but lacked documented evidence that facility leaders provided the patient’s family member the required information about potential compensation.The OIG made seven recommendations to the Facility Director related to care coordination agreements, compliance with Veterans Health Administration (VHA) Patient Aligned Care Team policies and VHA cancer registry requirements, and a review of both the root cause analysis and institutional disclosure to ensure alignment with VHA policies.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center suicide prevention initiatives)The OIG issued six recommendations for improvement in three areas:1. Quality, Safety, and Value• Defined governance structure2. Medical Staff Privileging• Ongoing Professional Practice Evaluationso Service-specific criteriao Data maintained in privileging folders• Evaluations by practitioners with equivalent specialized training and similar privileges• Executive Committee of the Medical Staff review3. Environment of Care• Clean and safe environment

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Central Arkansas Veterans Healthcare System, which includes the John L. McClellan Memorial Veterans’ Hospital (Little Rock), Eugene J. Towbin Healthcare Center (North Little Rock), and multiple outpatient clinics in Arkansas. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center suicide prevention initiatives)The OIG issued five recommendations for improvement in three areas:1. Quality, Safety, and Value• Root cause analysis2. Medical Staff Privileging• Defined time frames for Focused Professional Practice Evaluations3. Mental Health• Comprehensive Suicide Risk Evaluations• Suicide safety plans• Follow-up for patients at risk for suicide

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Alexandria VA Health Care System, which includes the Alexandria VA Medical Center and associated outpatient clinics in Louisiana. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on emergency department and urgent care center suicide prevention initiatives)The OIG issued four recommendations for improvement in two areas:1. Medical Staff Privileging• Completing Focused Professional Practice Evaluations• Reviewing Ongoing Professional Practice Evaluation data• Providers with equivalent specialized training and similar privileges completing Ongoing Professional Practice Evaluations2. Mental Health• Completing Comprehensive Suicide Risk Evaluations

The Office of the Inspector General (OIG) initiated this Special Inquiry following a radioactive release to the environment from the National Institute of Standards and Technology (NIST) test reactor located in Gaithersburg, Maryland on February 3, 2021. After the release, the NIST test reactor was shut down for more than two years before receiving authorization to restart from the U.S. Nuclear Regulatory Commission (NRC). This NIST event was one of eight unscheduled incidents or events in fiscal year 2021 that the NRC determined to be significant to public health or safety.This Special Inquiry’s focus broadened from the 2021 NIST event to include consideration of the NRC’s oversight of other Research and Test Reactor (RTR) facilities to assess potential systemic issues. However, this report primarily discusses the NRC’s oversight of the NIST test reactor prior to the February 2021 event because the event highlights areas in which the agency’s oversight could be improved as it relates to other smaller nuclear facilities.

We reviewed the U.S. Small Business Administration’s (SBA) oversight of Restaurant Revitalization Fund (RRF) recipients. The American Rescue Plan Act of 2021 authorized SBA to administer the RRF and provided $28.6 billion to assist eligible small businesses adversely affected by the Coronavirus Disease 2019 (COVID-19) pandemic.We determined program officials developed a plan for monitoring RRF award recipients use of funds and recovering unused or improperly awarded funds. However, program implementation was not executed in accordance with the plan.We made six recommendations for SBA to develop processes and procedures to improve oversight of RRF program recipients and recover unused or improperly awarded funds.

The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the EPA adhered to its tribal consultation policies during the development of:- The 2014 EPA Plan for the Federal Certification of Applicators of Restricted Use Pesticides within Indian Country.- The 2017 Certification of Pesticide Applicators rule revision.- The 2020 proposed revisions to the 2014 EPA Plan for the Federal Certification of Applicators of Restricted Use Pesticides within Indian Country.

To assist the Office of Personnel Management in assessing the reasonableness of retirement, health benefits, and life insurance withholdings and contributions, as well as enrollment information, we reviewed information submitted from multiple government agencies.