Federal Reports

The unclassified version of the SAR covers the period from 1 October 2021 – 31 March 2022, and reflects what the NSA OIG could release publicly about its work for that SAR Report Cover reporting period. The OIG made 171 recommendations that we believe will be impactful in improving the economy, efficiency, and effectiveness of this critical Agency's operations.

This administrative investigation addressed concerns of possible misconduct by two leaders responsible for overseeing medical facility staff training on implementing VA’s new multibillion-dollar patient electronic health record system. The investigation stemmed from a prior OIG review at the initial operating site (the Mann-Grandstaff VA Medical Center in Spokane, Washington), during which OIG healthcare inspectors experienced significant challenges in receiving timely, complete, and accurate information from the then VA Office of Electronic Health Record Modernization’s (OEHRM’s) Change Management group.The investigation revealed that while the Change Management leaders did not intentionally seek to mislead the OIG, their lack of diligence resulted in delays and misinformation being submitted that impeded oversight efforts. Failures included (1) submitting a training evaluation plan without disclosing to the OIG that it was in its “infancy” and had not been fully implemented or even approved; (2) delaying production of requested proficiency check datasets that should have been available under the submitted evaluation plan; (3) instead providing three summary statistics with errors that doubled the training proficiency test pass rate from initial findings of 44 to 89 percent, without the requested methodology; (4) overlooking red flags indicating that all failing scores had in fact been removed from reported rates (with the total number of proficiency tests dropping by more than 3,000 in submitted recalculations); and (5) failing to disclose concerns regarding data reliability and that data were excluded.VA concurred with the OIG’s two recommendations for providing guidance to staff in the since-reorganized Electronic Health Record Modernization and Integration Office on providing timely, complete, and accurate responses to OIG staff and ensuring direct staff-level communications with OIG personnel are not impeded. VA also agreed to consider whether administrative action is appropriate given the conduct and performance of the two Change Management leaders.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Chouteau Station in St. Louis, MO (Project Number 22-115-3). The Chouteau Station is in the Kansas-Missouri District of the Central Area and services ZIP Code 63110, which serves about 17,235 people and is considered to be urban. We judgmentally selected the Chouteau Station based on the number of Stop-the-Clock (STC) scans occurring at the delivery unit rather than at the customer’s point of delivery.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Maryville Gardens Station in St. Louis, MO (Project Number 22-115-2). The Maryville Gardens Station is in the Kansas-Missouri District of the Central Area and services ZIP Codes 63104, 63111, and 631181 which serve about 65,703 people and are all considered urban communities. We judgmentally selected the Maryville Gardens Station based on the number of Stop-the-Clock (STC) scans occurring at the delivery unit rather than at the customer’s delivery address.

This report presents the results of our self-initiated audit of the efficiency of operations at the St. Louis Processing and Distribution Center (P&DC) in St. Louis, MO (Project Number 22-112). We conducted this audit to provide U.S. Postal Service management with timely information on operational risks at this P&DC. We judgmentally selected the St. Louis P&DC based on a review of overtime; penalty overtime; late, extra, and cancelled trips by Postal Vehicle Service (PVS) and Highway Contract Route (HCR) drivers; and overall scanning performance. The St. Louis P&DC is in the Midwest Division, it processes letters and flats, and it services multiple 3-digit ZIP Codes in urban and rural communities (see Table 1).

We reviewed the EEOC’s payment integrity section of its FY 2021 AFR to assess the agency’s compliance with the requirements of PIIA, OMB guidance, and information on PaymentAccuracy.gov. We found that EEOC was not compliant with PIIA for FY 2021. The agency included a payment integrity section in the FY 2021 AFR in accordance with IPERIA. EEOC completed a risk assessment in FY 2020 and was not required to conduct a risk assessment in FY 2021. However, the agency did not conduct its annual OMB payment integrity review and data call resulting in our finding of non-compliance with PIIA.

Results of the Inspector General’s Fiscal Year 2021 Purchase and Travel CardProgram Risk Assessment

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 Martinsburg VA Medical Center. The inspection covered key clinical and administrative processes associated with promoting quality care. It focused on 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.At the time of the OIG’s virtual inspection, the medical center’s executive leadership team had worked together for just over one month. Employee survey data revealed opportunities for the Director; Chief of Staff; and Associate Director, Patient Care Services to reduce staff feelings of moral distress at work. Patient experience survey data indicated that leaders had an opportunity to improve female respondents’ inpatient and specialty care experiences. The OIG’s review of the medical center’s accreditation findings did not identify any substantial organizational risk factors. However, the OIG identified concerns related to sentinel events and institutional disclosures. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued nine recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Sentinel events and institutional disclosures(2) Quality, Safety, and Value• Systems Resign and Improvement Program• Surgical work group attendance(3) Care Coordination• Patient transfer monitoring and evaluations• Inter-facility transfer forms• Medication list transmission(4) High-Risk Processes• Disruptive behavior committee attendance• Staff training