Federal Reports

This audit report is one of a series of OIG reports addressing the identification, reporting, and investigation of incidents of potential abuse or neglect of our Nation’s most vulnerable populations, including the elderly and individuals with developmental disabilities. Our objectives were to determine whether Florida: (1) ensured that nursing facilities reported potential abuse or neglect of Medicaid beneficiaries transferred from nursing facilities to hospital emergency departments; (2) complied with Federal requirements for assigning a priority level, initiating onsite surveys, and recording allegations of potential abuse and neglect; and (3) operated its incident report program effectively.

We audited $212.4 million of costs billed to the Tennessee Valley Authority (TVA) by G·UB·MK Constructors (GUBMK) under Contract No. 11514 to determine if costs billed to TVA were in compliance with contract's terms. We determined the costs billed by GUBMK generally complied with the contract except for $22,545. (Summary Only)

We determined that FEMA did not ensure procurements and costs for debris removal operations in Monroe County, Florida, met Federal requirements and FEMA guidelines.  Specifically, FEMA did not adequately review local entities’ procurements for debris removal projects and reimbursed local entities for questionable costs.  These deficiencies were due to weaknesses in FEMA training and its quality assurance process.  As a result, FEMA approved reimbursement to local entities for nearly $25.6 million (more than $23 million in Federal share) for debris removal projects, including contracts that may not have met Federal procurement requirements, and more than $2 million in questionable costs.  Without improvements to FEMA’s training and project review processes, FEMA risks continuing to expose millions of dollars in disaster relief funds to fraud, waste, and abuse.  We made three recommendations with which FEMA officials concurred.  Based on the information FEMA provided, we consider the three recommendations resolved and open.  

This review examined how effectively Veterans Benefits Administration (VBA) managers fulfilled the plan VA was required to submit to Congress for a skills certification program for claims processors. The program includes a required test to ensure staff have the skills, knowledge, and abilities needed to accurately carry out their tasks.The OIG found VBA did not meet the skills certification requirements for fiscal years (FYs) 2016 through 2019. Specifically, based on a statistical sample, the OIG estimated 4,700 of 10,800 individuals required to take the exam were not tested. The program also did not provide individual training plans to about 1,900 of the 2,500 employees who failed the test, or ensure that all staff who failed took the next scheduled test. Further, VBA did not take personnel actions against an estimated 98 percent of employees who failed consecutive tests after receiving remedial training.Several factors contributed to the identified issues, including an insufficient process for identifying and notifying those required to take the test and data limitations affecting tracking. In addition, VBA did not design tests for all employees cited in the plan. Testing was cancelled in FY 2018 because of intranet technical issues and in FY 2019 to assess the effectiveness of testing.The OIG made six recommendations regarding written guidelines for individuals required to or exempted from taking tests; a tracking mechanism for eligible test takers; updates to Congress on why not all claims-processing positions are subject to testing; plans to train staff who failed tests; an oversight plan to ensure individuals who failed consecutive tests were retrained; and notifying Congress of plans to take personnel actions against individuals who fail consecutive tests after remediation, as required by law.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 7: VA Southeast Network in Duluth, Georgia, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this unannounced visit during concurrent inspections of VISN 7 facilities.In September 2019, VHA reassigned the Network Director and Chief Medical Officer, and appointed acting leaders to fill their roles following reports that a Community Living Center patient was bitten by hundreds of ants. The leadership team had worked together for almost five months at the time of the visit. Selected survey scores regarding employee satisfaction revealed opportunities for the acting Chief Medical Officer to improve attitudes toward leaders and for the Deputy Network Director and Quality Management Officer to improve feelings of moral distress at work. Patient experience survey scores were lower than VHA averages. The VISN leaders have an opportunity to improve employee and patient satisfaction. The leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes.The OIG issued seven recommendations for improvement in three areas:(1) Environment of Care• VISN comprehensive environment of care program policy• VISN Emergency Management Committee processes(2) Women’s Health• Quarterly program updates to executive leaders• Annual site visits at each facility• Staff education gap assessments(3) High-Risk Processes• VISN-led facility reusable medical equipment inspection results