Federal Reports

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 Hunter Holmes McGuire VA Medical Center and associated outpatient clinics in Virginia. The inspection covered key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.When the team conducted this inspection, the medical center’s leaders had worked together in their positions for 19 months. Employee survey results highlighted opportunities to improve employee attitudes toward leaders and the workplace, and reduce staff feelings of moral distress. Patient survey results identified opportunities to improve care experiences. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify substantial organizational risk factors. The executive leaders spoke knowledgeably within their scope of responsibilities about VHA data and factors contributing to poorly performing quality and efficiency measures.The OIG issued nine recommendations for improvement in three areas:(1) Quality, Safety, and Value• Tracking of improvement capabilities and projects• Peer review processes• Surgical death reviews(2) Care Coordination• Inter-facility transfer monitoring and evaluation• Transfer form completion• Medical record transmission(3) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training

The objective was to evaluate I&A’s responsibility for providing intelligence to state and local officials in advance of the January 6 events, and whether and how I&A fulfilled its responsibility.

Reporting Required by Government Auditing Standards section is solely to describe the scope of our testing of internal control and compliance with selected provisions of applicable laws, regulations.

The Charge Card Act requires the OIG to conduct periodic reviews of DFC’s charge card program for illegal, improper, or erroneous transactions to prevent fraud, delinquency, or misuse.Our objectives were to (1) determine the level of risk of illegal, improper, or erroneous purchases and payments; (2) determine the scope, frequency, and number of audits or reviews to be conducted on the basis of a risk assessment; and (3) address the requirements of the Charge Card Act, OMB, and General Services Administration (GSA) requirements and standards. This was our first audit of DFC’s compliance with the Charge Card Act.

The U.S. International Development Finance Corporation Office of Inspector General (DFC OIG) contracted with RMA Associates, LLC to audit DFC’s compliance with the Digital Accountability and Transparency Act (DATA Act) for the second quarter of fiscal year 2021. Our objectives were to (1) assess the completeness, accuracy, timeliness, and quality of the second quarter fiscal year 2021 financial and award data submitted by DFC for publication on USASpending.gov; and (2) assess DFC’s implementation and use of the government-wide financial data standards established by the Office of Management and Budget (OMB) and U.S. Department of the Treasury. This was our first audit of DFC’s compliance with the DATA Act.