Federal Reports

The Office of Inspector General examined $22 million in NASA grants awarded to the Space Science Institute (SSI), a nonprofit research and education corporation based in Boulder, Colorado.

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Kansas City VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The executive leaders were permanently assigned. Selected survey scores related to employees’ satisfaction were generally similar to or better than VHA averages. However, opportunities exist for the associate director for Patient Care Services to improve employee satisfaction. The leaders appeared to support efforts to improve and maintain patient safety and quality care. The OIG’s review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The leaders were knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance contributing to the facility’s SAIL “2-star” quality rating. The OIG issued 14 recommendations: (1) Quality, Safety, and Value • Peer review of applicable deaths and suicides • Interdisciplinary review of utilization management data (2) Environment of Care • Safety, infection prevention, and emergency management processes • Locked inpatient mental health unit security (3) Controlled Substances Inspections • Controlled substances reconciliation (4) Military Sexual Trauma Follow-up and Staff Training • Military sexual trauma mandatory training (5) Geriatric Care • Patient/caregiver education on medications • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership and reports to leadership (7) Emergency Department and Urgent Care Center • Backup call schedule for providers

The National Security Agency Office of the Inspector General (NSA OIG) announced its release of an unclassified summary of its Special Study of NSA Controls to Comply with Signals Intelligence Retention Requirements. A classified version of the report that was completed earlier this year formed the basis for the unclassified summary.

Windows Operating System Software Management

We audited the Wausau Community Development Authority’s Housing Choice Voucher Program based on our analysis of risk factors related to the public housing agencies in Region 5’s jurisdiction (States of Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin). The audit was part of the activities in our fiscal year 2019 annual audit plan. Our audit objective was to determine whether the Authority administered its program in accordance with the U.S. Department of Housing and Urban Development’s (HUD) and its own requirements. Specifically, we wanted to determine whether the Authority ensured that its program units met HUD’s housing quality standards.The Authority generally complied with HUD’s and its own requirements regarding housing quality standards inspections of its program units. However, it did not always ensure that housing quality standards deficiencies were corrected in a timely manner. As a result, program participants were subjected to living in units that may not have been decent, safe, and sanitary.We recommend that the Director of HUD’s Milwaukee Office of Public Housing require the Authority to develop and implement adequate enforcement procedures that support its policy and ensure that housing quality standards deficiencies are corrected in a timely manner.