Federal Reports

The VA Office of Inspector General’s (OIG) Office of Investigations was contacted by the Facility Director in June 2018 who reported concerns related to the suspicious deaths of nine patients from profound hypoglycemia (low blood sugar). A criminal investigation was initiated. The OIG Office of Healthcare Inspections immediately commenced a parallel healthcare inspection. Healthcare inspectors finalized their evaluation after OIG investigators completed the criminal case.On July 14, 2020, Reta Mays, a former nursing assistant, pled guilty to seven counts of second degree murder and one count of assault with the intent to commit murder by deliberately administering insulin to eight patients.The OIG found that the facility had serious clinical and administrative failures, including hiring and medication security practices, communication of clinical information, and patient safety deficiencies that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier.The OIG made three recommendations to the Under Secretary for Health related to adjudicator follow-up of unreturned background investigation documentation, rescue medication security and management, and mortality data analyses. Two recommendations were made to the Veterans Integrated Service Network Director to conduct management reviews of the care of patients discussed in this report and a broader evaluation of patients who may have been harmed in other ways by Ms. Mays’s actions. Ten recommendations were made to the Facility Director related to the Pharmacy Service’s inventory accountability, endocrinology consults, clinical communication expectations, clinical documentation reviews, clinical care-related reporting expectations, patient safety event training, interdisciplinary mortality workgroup activities, oversight and reporting, and a culture of safety.

The EPA and states can reduce the volume of trash, including plastics, in U.S. waterways by evaluating barriers to implementing the Clean Water Act and developing strategies to overcome those barriers.

We investigated allegations that a National Park Service (NPS) supervisor took Government property for personal use and misused her official position. The NPS subsequently notified us that one of the supervisor’s subordinate employees also took Government computer equipment for personal use.We found that the NPS supervisor and two subordinate employees took Government property for personal use. We also found that the NPS supervisor misused two subordinates’ official time by directing them to perform work on her personal property for her personal benefit. Lastly, we found that park officials did not ensure that the subordinate employees received mandatory property disposal training.The NPS supervisor admitted guilt of felony theft and was accepted into a diversion program that, if successfully completed, would lead to dismissal of a felony theft charge. Based on that charge and an interim report of our findings, the NPS subsequently issued the supervisor a 14 calendar-day suspension without pay. She paid the NPS $3,964 in restitution.

The National Park Service (NPS) provided $12.7 million to the Puerto Rico State Historic Preservation Office (PRSHPO) in fiscal year (FY) 2019 for the repair and restoration of historic sites damaged in 2017 by Hurricanes Irma and Maria. The PRSHPO received a considerably smaller amount in prior FYs—approximately $1.3 million combined for FYs 2017 and 2018. Due to the significant increase in funding in FY 2019, the NPS requested that we conduct a financial audit of the PRSHPO’s accounting system to ensure that it could properly account for the increased funding.Our audit found deficiencies in how labor expenses were recorded, tracked, and reported. We also found that the PRSHPO did not have a policy or procedures as an internal control for ensuring compliance with Federal statutes, relevant regulations, and terms and conditions of a Federal award as required by the Code of Federal Regulations.We make five recommendations to help the PRSHPO improve its accounting system. In response to our draft report, the NPS and the PRSHPO concurred with our findings and recommendations.

A prior OIG audit found that Medicare paid providers that had billed for medically unnecessary laboratory tests. Our preliminary review of Medicare claims identified providers that billed for direct-measurement, low-density lipoprotein (LDL) cholesterol tests (direct LDL tests) and lipid panels (a blood test that reports four measures of lipids, including LDL cholesterol) for the same beneficiary on the same date of service; some of these providers billed the direct LDL test every time they billed the lipid panel. These claims were at risk of noncompliance with Medicare requirements because, according to the Centers for Medicare & Medicaid Services (CMS), billing for a direct LDL test in addition to a lipid panel, while sometimes medically necessary, should happen with only limited frequency.Our objective was to determine whether payments made to providers for direct LDL tests that were billed in addition to lipid panels for the same beneficiary on the same date of service complied with Medicare requirements.Our audit covered Medicare Part B payments of about $35 million for direct LDL tests that were billed in addition to lipid panels for the same beneficiary on the same date of service and that had dates of service from 2015 through 2019 (audit period).