Federal Reports

The VA Office of Inspector General (OIG) initiated a healthcare inspection at the Richard L. Roudebush VA Medical Center (facility) in Indianapolis, Indiana, to assess allegations and concerns related to the availability of on-call interventional radiology services. In May 2024, VA clarified that fee basis provider duties must be related to direct patient care activities, which prevented VA from paying providers for being on call and available to provide patient care services. In response, the facility halted on-call interventional radiology services, which were later resumed intermittently using facility providers.  

The OIG did not substantiate the allegation that a waiver request should have been submitted prior to the reduction in coverage. However, the OIG substantiated that confusion and deficient communication of intermittent on-call coverage led to a patient being unnecessarily transferred after developing a gastrointestinal bleed, despite services being available at the facility. The resumption of coverage on an intermittent basis was communicated to staff and leaders through emails and daily calls. However, the patient’s intensive care unit (ICU) attending physician and the ICU director were not included in the email communication and did not participate in the daily calls. Further, the ICU fellow who transferred the patient did not consult with the ICU attending physician and the gastroenterology fellow did not document assessing the patient as required. 

The OIG determined that a clinical or institutional disclosure was not conducted, facility leaders did not conduct a comprehensive review of the event to understand staff’s involvement, and quality management staff did not process a related patient safety report in accordance with VHA policy.

The Facility Director concurred with the six recommendations and shared plans and actions taken to address communication, documentation, disclosure, patient safety reporting, mitigation of risks that contributed to the transfer, and rejected patient safety reports. 

Our objective was to assess the Space Weather Follow-On (SWFO) program’s progress in preparing the SWFO-L1 satellite for launch and operations. To meet our objective, we reviewed SWFO-L1 satellite environmental testing, planning for integration onto the launch vehicle as a rideshare, and operational readiness reviews. We also reviewed the extent to which NOAA had policies governing the launch of space weather satellites. Additionally, we compared the program management of risk, cost, and schedule against programmatic plans. We found that the SWFO program made adequate progress in preparing for launch and operations. However, we also found that the SWFO Program Office did not conduct vibration testing using the actual flight separation system, nor did it receive a formal waiver for this deviation from “Test-As-You-Fly” (TAYF) standards. This occurred because NOAA oversight officials, as the mission sponsors, did not provide sufficient oversight to enforce TAYF requirements during vibration testing. As a result, NOAA did not have assurance that the system would not fail during launch and that the government’s interest was adequately protected.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the EPA implemented effective controls during the selection of Track I grant awardees through the Community Change Grants Program within the EPA Office of Environmental Justice and External Civil Rights.
 

Summary of Findings

The EPA implemented effective controls during its review and selection of Track I Community Change Grants Program applications. The EPA adhered to its Policy for Competition of Assistance Agreements and other applicable requirements during the application review process. Additionally, the EPA ensured that Track I grant awardees met the eligibility requirements stated in the Inflation Reduction Act.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.