Federal Reports

The Office of Inspector General issued a report discussing the Top Management and Performance Challenges facing NASA.

In 2018, senior DHS and U.S. Customs and Border Protection (CBP) leaders issued public statements urging undocumented aliens seeking asylum to enter the United States legally at ports of entry, while also directing ports of entry to focus on other priority missions and institute practices to limit the number of undocumented aliens processed at ports of entry. CBP Office of Field Operations (OFO) personnel at 24 Southwest Border ports of entry implemented a practice known as queue management, where an officer manned a “limit line” position at or near the U.S.-Mexico border to control the number of undocumented aliens entering the port. We identified that seven of these ports stopped processing virtually all undocumented aliens, including asylum seekers, by redirecting them to other ports located miles away. This redirection contravenes CBP’s longstanding practice to process all aliens at a “Class A” port of entry or reclassify the port of entry. Additionally, CBP officers at four ports returned undocumented aliens to Mexico despite a legal requirement to process asylum claims of aliens that are physically present in the United States. We made three recommendations aimed at bringing CBP’s practices in line with Federal law and regulations and promoting efficient processing of undocumented aliens. CBP concurred with two of the recommendations and did not concur with one. CBP defended its decision to redirect undocumented aliens at seven ports citing the availability of operational capacity and resources and the need to maintain a discretionary balance between mission requirements at each port.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Carl Vinson VA Medical Center and multiple outpatient clinics in Georgia. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.The executive leadership team had worked together for five weeks prior to the OIG’s on-site visit. The leadership team had vacancies in three of the four key positions since the previous healthcare inspection. Survey results revealed opportunities for the executive team to improve employee satisfaction. Patient experience survey results were generally less favorable than Veterans Health Administration national averages. The OIG’s review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning data.The OIG issued 17 recommendations for improvement in seven areas:(1) Quality, Safety, and Value• Committee processes(2) Medical Staff Privileging• Professional practice evaluations• Provider exit reviews(3) Medication Management• Quality measure oversight(4) Mental Health• Suicide prevention training(5) Care Coordination• Goals of care conversations(6) Women’s Health• Women’s health primary care providers• Committee membership and attendance(7) High-Risk Processes• Reusable medical equipment inventory file• Standard operating procedures• Annual risk analysis• Eyewash station testing• Quality assurance monitoring• Reprocessing and storage area physical inspections• Competency assessments

What We Looked AtWe contracted with the independent public accounting firm Allmond & Company, LLC, to audit the National Transportation Safety Board’s (NTSB) financial statements as of and for the fiscal years ended September 30, 2020, and September 30, 2019, provide an opinion on those financial statements, and report on internal control over financial reporting, compliance with laws, and other matters. The contract requires the audit to be performed in accordance with U.S. generally accepted Government auditing standards, Office of Management and Budget audit guidance, and the Government Accountability Office’s and Council of the Inspectors General on Integrity and Efficiency’s Financial Audit Manual. We performed a quality control review of Allmond’s report dated November 6, 2020, and related documentation, and inquired of its representatives. What We FoundOur quality control review disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards. RecommendationsAllmond made no recommendations.