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 Palo Alto Health Care System in California. 

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

The OIG issued four recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Staff access to shared bathrooms
     •    Keeping exterior doors closed
     •    Separate clean and dirty storage
   2.    Patient safety
     •    Service-level workflows for test result communication

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Lovell Federal Healthcare System in North Chicago, Illinois. 

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

The OIG issued three recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Endoscope storage
   2.    Patient safety
     •    Service-level workflows for test result communication
     •    External Peer Review Program deficiencies

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 Loma Linda Healthcare System in California. 

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

The OIG issued eight recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Community living center dementia unit shower room safety
     •    Emergency Department patient privacy assessment
     •    Eyewash station cleanliness and function
   2.    Patient safety
     •    Test result communication policy
     •    Service-level workflows
     •    VHA policy change processes
     •    Test result communication performance metrics
     •    Quality and Patient Safety Council meeting attendance

The Office of Inspector General initiated this audit to review the $5,872,733,964 of costs claimed by Consolidated Nuclear Security, LLC (CNS) to manage and operate the Pantex Plant and the Y-12 National Security Complex for fiscal years (FY) 2016 through 2018.

CNS managed and operated both the Pantex Plant and the Y-12 National Security Complex as a management and operating contractor for the Department of Energy’s National Nuclear Security Administration.

Specifically, the audit objective was to determine if costs charged to Department Contract No. DE-NA0001942 for FYs 2016 through 2018 were allowable, allocable, and reasonable in accordance with appliable laws, regulations, and contract terms.

We identified one noncompliance and one control deficiency. We questioned approximately $324,000 of costs claimed by CNS in its Statement of Cost Incurred and Claimed in FYs 2016 and 2017 for unworked overtime due to an administrative error. We also found that CNS improperly classified subcontracts as firm-fixed-price due to control deficiencies in subcontract administration.

To address the issues identified in this report, we made two recommendations that, if fully implemented, should reduce the risk of reimbursing unallowable costs. Further, we recommend that CNS work with the contracting officer to resolve the questioned costs identified in this report.

CNS concurred with our recommendations; however, it did not agree with all the information presented in the report specifically related to an investigative matter.

We found that an energy company failed to pay required Federal royalties on production from wells in Yuma County, Colorado.