Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the facility to assess concerns about the diagnosis and treatment of anemia and coordination of a colonoscopy for a patient who subsequently died.The patient had iron-deficiency anemia. The OIG found the primary care provider evaluated and effectively treated the anemia with iron supplements.In 2017, the patient developed a blood clot, which required anticoagulant treatment. In 2018, the patient developed an abnormal heart rhythm and remained on an anticoagulant. The OIG determined that the anticoagulant was managed appropriately and did not clinically affect the patient’s anemia.Late 2020, the patient was admitted to the facility with rectal bleeding and weakness. The patient received a blood transfusion and gastroenterology evaluation. The patient had no further symptoms and was discharged. An outpatient colonoscopy was scheduled.One day later, the patient was readmitted for dizziness. Laboratory testing indicated possible heart muscle damage. Cardiology staff recommended an anemia workup and blood transfusions as needed. The hospitalist discontinued the anticoagulant and requested gastroenterology staff perform the colonoscopy during the admission. The patient had no further symptoms for two days.The morning before a scheduled colonoscopy, the patient experienced chest pain and was transferred to the intensive care unit. Cardiology staff recommended a cardiac catherization but requested gastroenterology staff first determine the cause of and treat the patient’s bleeding. Two days later, gastroenterology staff performed the colonoscopy and treated the source of the bleeding. The following day, towards the end of the cardiac catheterization, the patient developed cardiac arrest, and could not be resuscitated.The OIG found the timing of the patient’s colonoscopy to be clinically appropriate. Providers evaluated the patient across two hospital admissions and adjusted the timing of the colonoscopy to meet the patient’s clinical needs.

VA has one of the largest acquisition functions in the federal government; its contracting officers obligated approximately $36.9 billion in fiscal year 2020 alone. A warrant gives federal contracting officers the authority to obligate taxpayer dollars. VA’s contracting officers help serve our nation’s veterans by procuring the goods and services required for their care and support.However, there have been long-standing concerns with VA’s contracting officer warrant program. Since 2015, the VA Office of Inspector General (OIG) has issued multiple reports in which warranted contracting officers exceeded their authority or made decisions that put veterans and VA facilities, resources, and information systems at risk. In addition, VA’s acquisition management has been included on the Government Accountability Office’s high-risk list. The OIG conducted this review to determine whether VA had an effective contracting officer warrant program.The OIG found that while VA’s contracting officer warrant program complied with Federal Acquisition Regulation requirements, opportunities exist to strengthen the program. VA lacked assurance that all contracting officer warrants were justified and necessary. Additionally, VA did not have sufficient data to effectively staff and distribute contracting officers’ workload. The OIG also found that additional guidance would be useful in determining when and how to reinstate warrants to individuals with past performance issues. Improved consistency in other areas, such as warrant board procedures, officer selection, and warrant transferability, would also strengthen the program.The OIG made three recommendations to strengthen VA’s warrant program, to include assessing the warrant justification template, determining whether to implement additional formalized procedures to monitor contracting officer workload, and increasing the consistency and standards of practices.

The coronavirus pandemic negatively impacted the oversight and assistance that Regions 9 and 10 provide to the tribal drinking water systems under their purview, as well as the capacity of these systems to provide safe drinking water. The pandemic also underscored the limitations of both EPA resources and tribal drinking water system resiliency. As a result, tribal drinking water systems may be unable to operate safely and comply with drinking water regulations. Access to safe and clean water is critical at all times, but even more so during pandemic situations.

To see our report, click on the link below

What We Looked AtBetween fiscal years 2013 and 2018, the Federal Aviation Administration (FAA) awarded over $17 billion in contracts. Within FAA, three key categories of acquisition professionals work together to award and manage contracts critical to meeting the mission of the agency: Contracting Officers (COs), Contracting Officer's Representatives (CORs), and Program/Project Managers (P/PMs). However, our prior work has raised concerns about the adequacy of FAA's acquisition workforce certification and warrant practices. Given the importance of a high-performing acquisition workforce in managing FAA's multibillion-dollar contract budget, we conducted this audit. Specifically, our audit objective was to assess FAA's oversight and compliance with Federal and Agency requirements for acquisition workforce training, certification, and warrants.What We FoundFAA faces challenges in tracking its acquisition workforce and ensuring compliance with training, certification, and warrant requirements. First, FAA lacks effective processes for identifying, tracking, and assessing its acquisition workforce. For example, FAA relies on six separate information systems to identify and track its COs, CORs, and P/PMs, making it difficult to ensure the accuracy and completeness of the Agency's workforce-related data. In addition, until recently, FAA had been using the Federal Acquisition Institute's Acquisition Training System (FAITAS) as its system of record for tracking whether acquisition professionals have required certifications. Yet, more than 5 years after adopting FAITAS, FAA did not fully implement nor ensure its use. Second, FAA does not ensure its acquisition workforce meets all certification and warrant requirements. For example, FAA grants COs varying levels of warrant authority authorizing them to obligate funds on the Government's behalf. However, we found that 6 of 46 COs were assigned to contracts without the required certification level to support their warrant. Further, almost half the CORs in our sample (32 out of 69) were uncertified and yet had been assigned to contracts totaling $184 million. As a result, FAA may be putting Federal funds at risk by allowing its acquisition workforce to manage contracts without the experience, training, and certifications required to manage highly complex, costly, and mission-critical acquisitions.Our RecommendationsFAA concurred with our eight recommendations to improve its oversight and compliance with certification, training, and warrant requirements for COs, CORs, and P/PMs. We consider all recommendations resolved but open pending completion of planned actions.