Federal Reports

The VA Office of Inspector General (OIG) evaluated the Veterans Health Administration’s (VHA’s) attention deficit hyperactivity disorder (ADHD) diagnostic assessment practices, stimulant medication (stimulant) prescribing practices, training expectations, and policies. A diagnosis of ADHD must be established by a qualified provider based on diagnostic criteria. Stimulants are approved to treat ADHD and classified as controlled substances because of the risk for abuse. ADHD diagnoses and stimulant prescribing to treat adult ADHD have increased in recent decades.Prescribers insufficiently documented support for ADHD diagnoses corresponding to new stimulant prescriptions. Additionally, most electronic health records included documentation of a diagnostic interview, while fewer documented other assessment methods.The OIG found that prescribers inadequately assessed the risks and contraindications of stimulants prescribing, such as cardiac risks and urine toxicology testing. Prescribers assessed risks through the prescription drug monitoring program queries consistent with VHA expectations of 75 percent for new and 95 percent for active controlled substance prescriptions. The OIG would expect the query goal for new controlled substance prescriptions to meet or exceed the goal established for active prescriptions.The OIG found deficiencies in prescribers’ reported ADHD diagnostic and stimulant-prescribing training and knowledge. Among survey respondents, 13 percent of mental health and 65 percent of primary care respondents reported being somewhat or not knowledgeable about prescribing stimulant medication for the treatment of ADHD. The OIG determined that VHA has no established policies or clinical practice guidance related to ADHD assessment, diagnosis, and treatment. The lack of ADHD-related policies may contribute to limited awareness of clinical expectations and resources.The OIG made five recommendations to the Under Secretary for Health related to diagnostic assessment, assessment of risks and contraindications, prescription drug monitoring program goals, the referral process for complex mental health conditions, and ADHD policy and clinical practice guidance.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Northern Indiana Health Care System, which includes the Fort Wayne and Marion VA Medical Centers, multiple outpatient clinics in Indiana, and an outpatient clinic in Ohio. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued 10 recommendations for improvement in three areas:1. Medical staff privileging• Focused Professional Practice Evaluation time frames• Privileges based on Ongoing Professional Practice Evaluation activities2. Environment of care• Corrugated containers• Clean and free of dust and soiling• Clean patient care areas• Expired commercial products• Clean and dirty equipment storage• Walls allow thorough cleaning• Inpatient Mental Health Unit over-the-door alarm testing3. Mental health• Comprehensive Suicide Risk Evaluation completion

We contracted with the Institute for Defense Analyses (IDA), an independent firm, to perform this evaluation. Our office oversaw the evaluation’s progress to ensure that IDA performed it in accordance with the Council of the Inspectors General on Integrity and Efficiency’s Quality Standards for Inspection and Evaluation (December 2020) and contract terms. However, IDA is solely responsible for the attached report and the conclusions expressed in it. The evaluation objective was to determine whether NOAA Fisheries grantees and subrecipients accounted for and expended pandemic relief funds provided under the Coronavirus Aid, Relief, and Economic Security Act and subsequent funding authorizations in accordance with federal laws and regulations. IDA found that (1) a dashboard helped NOAA monitor execution progress of most funding; however, NOAA had little to no oversight of CAA funding for the Tribes; (2) some states and territories employed more rigorous processes and internal controls to identify potential incorrect payments; and (3) some states, Tribes, and territories were slower to distribute funds and less effective at targeting fishery participants with greater than 35 percent loss.

What We Looked AtIn 2023, we conducted a quality control review (QCR) of Crosslin PLLC’s single audit of the Metropolitan Transit Authority (MTA) of Nashville, TN, for the fiscal year that ended June 30, 2022 (OIG Report Number QC2023046, dated September 25, 2023). In that QCR, we found that Crosslin’s audit work did not comply with the requirements of the Single Audit Act, the Uniform Guidance, and the U.S. Department of Transportation’s (DOT) major program. Specifically, Crosslin found a noncompliance that it decided not to report. Auditing guidelines require auditors to include in their work papers reasonable bases for not reporting noncompliance, but we found that Crosslin’s basis was not reasonable. As a result, Crosslin had to either include in its work papers a reasonable basis for not reporting the noncompliance or reissue its report on the single audit. On February 7, 2024, Crosslin reissued its single audit report that included MTA’s Procurement and Suspension and Debarment noncompliance, and questioned costs totaling approximately $68,000 that resulted from the noncompliance.We performed a follow up QCR on Crosslin’s revised single audit of MTA. Our objectives were to determine whether (1) the revised audit work complied with the Single Audit Act of 1984, as amended, the Office of Management and Budget’s Uniform Guidance, and the extent to which we could rely on the auditors’ revised work on DOT’s major program and (2) MTA’s revised reporting package complied with the reporting requirements of the Uniform Guidance.What We FoundCrosslin complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT’s major program. We found nothing to indicate that Crosslin’s opinion on DOT’s major program was inappropriate or unreliable. In addition, we did not identify deficiencies in MTA’s reporting package that required correction and resubmission. Accordingly, we assigned Crosslin a rating of pass.

Objective: To determine the risk of illegal, improper, and erroneous purchases made through the Social Security Administration’s charge card programs.

The Office of Inspector General (OIG) is issuing this inspection report to present the results of our assessment of the U.S. Small Business Administration’s (SBA) initial response to Hurricane Idalia, including staffing, loan application volume, and timeliness of disaster loan approvals.We found SBA’s initial response to Hurricane Idalia was timely and effective. The agency established a field presence within 3 business days and opened a Business Recovery Center within 10 business days for both Florida and Georgia. Additionally, SBA was responsive to the increase in loan applications that resulted from the hurricane.Residents reported positive experiences with the customer service received at the recovery centers.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Oscar G. Johnson VA Medical Center, which includes multiple outpatient clinics in Michigan and Wisconsin. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued three recommendations for improvement in two areas:1. Leadership and organizational risks• Identification of sentinel events for home oxygen fires• Veterans Integrated Service Network tracking and monitoring of root cause analyses2. Mental health• Completion of Comprehensive Suicide Risk Evaluations

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Maine Healthcare System, which includes the Togus VA Medical Center and multiple outpatient clinics in Maine. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued 12 recommendations for improvement in all five areas:1. Leadership and organizational risks• Sentinel events and institutional disclosures2. Quality, safety, and value• Root cause analysis for patient safety events3. Medical staff privileging• Ongoing Professional Practice Evaluation data• Focused Professional Practice Evaluation reporting• VISN oversight of credentialing and privileging processes4. Environment of care• Environment of care inspections• Panic and over-the-door alarm testing• Maintaining a safe environment• Hazard warning signs• Safe and clean patient care areas5. Mental health• Comprehensive Suicide Risk Evaluation completion

An Amtrak Assistant Passenger Conductor based in Philadelphia violated company policy by altering her company paystub for July 2022 and submitting it to a financial institution for the purpose of securing a mortgage loan. On April 2, 2024, the employee received a final warning after she waived her right to a hearing and accepted responsibility for the charges.