Federal Reports

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Atlanta Healthcare System in Decatur, Georgia. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued seven recommendations for improvement in five domains:
   1.    Culture
     •    Infrastructure issues
     •    Unanswered veteran phone calls
   2.    Environment of care
     •    Parking garage emergency call boxes
   3.    Patient safety
     •    Local test result policies and memorandums
     •    Institutional disclosures for adverse events
   4.    Primary care
     •    Panel sizes and access to care
   5.    Veteran-centered safety net
     •    Medical clearances for veterans in the Compensated Work Therapy program

To address occupational shortages and support hiring efforts, VA leverages federal regulations that allow agencies to offer recruitment, relocation, and retention incentives to encourage candidates to accept positions that are difficult to fill or to keep high-quality staff. The OIG conducted this audit to evaluate VA’s controls over and governance of the use of these incentives for VHA positions. Although these types of incentives were used mostly for positions on staffing shortage lists, VA did not effectively govern the incentive process to ensure responsible VHA officials consistently captured mandatory information necessary to support an incentive award. The OIG team estimated 30 percent of incentives paid during fiscal years 2020 through 2023 were missing forms, lacked a sufficient justification, or were missing signatures. As a result, VHA paid employees about $340.9 million in incentives that were not adequately supported. Furthermore, the OIG team found VHA did not consistently include sufficient workforce and succession plan narratives for an estimated 20 percent of retention incentives, note employee performance ratings for 7 percent of relocation incentives, or obtain self-certifications for about 71 percent of employees who relocated. The team also identified 28 employees who received retention incentive payments up to an additional 11 and a half years after their award period had expired. VA improperly paid about $4.6 million to these employees for incentives that should have been terminated. The OIG made eight recommendations to improve the oversight of these incentives.

OIG reviewed USDA’s performance measures and monitoring for the Partnerships for Climate-Smart Commodities.