Federal Reports

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

The OIG found approximately half of the DNFSB’s planned Review Agendas for Fiscal Years 2019 through 2024 were carryovers from prior years.  Some of these carryover reviews were delayed, and in those cases, justifications for delays were not consistently recorded.  Moreover, the OIG found that the DNFSB does not have a structured Knowledge Management Program, and DNFSB Review Agenda guidance is not aligned with its current process.

The report contains three recommendations to update and improve the agency’s Review Agenda process.  

Standing Review Boards (SRB) conduct independent assessments of programs and projects and offer recommendations to improve performance and reduce risk. However, the SRB process lacks Agency-level oversight, improved SRB composition and training can add greater value to the assessments, improvements are needed to ensure adequacy of SRB engagement and accuracy of information provided to decision-makers, and the SRB process does not adequately capture lessons learned.

The VA Office of Inspector General (OIG) conducted a healthcare inspection related to the care of a resident at the Batavia community living center (CLC), a part of the VA Western New York Healthcare System (system).

In late winter 2024, Resident A was admitted to the Buffalo VA Medical Center (VAMC) for combativeness, agitation, and confusion. After the resident’s dementia-related behaviors were controlled, the resident was admitted to the Batavia CLC and received 21 doses of injectable antipsychotic medications throughout the 23-day stay. On CLC day 20, the resident’s elevated fingerstick blood sugar level was not reported to a physician for treatment and on CLC day 23, the level was more than four times the system’s upper limit of normal. The resident was admitted to a community hospital, then hospice at the Buffalo VAMC, and died shortly thereafter.

The OIG substantiated that ongoing and cumulative deficiencies, including (1) physician and nursing staff management of Resident A’s dementia and diabetes and (2) nursing documentation of medication administration and nutritional intake, may have contributed to the resident’s preventable decline in health, which necessitated end-of-life care. 

The OIG found similar deficiencies in care for a second resident and identified concerns regarding leaders’ response to clinical care deficiencies, including a failure to enter a patient safety report regarding Resident A’s elevated fingerstick blood sugar result on CLC day 20. Once aware of care concerns, system leaders’ response included temporarily removing the chief geriatric physician and initiation of clinical and administrative investigations. Further, the OIG identified deficiencies in provider staffing and nurse education that increase risk to patient safety and may have contributed to Resident A’s functional decline.

The OIG made 10 recommendations to the System Director regarding dementia and diabetes care, quality assurance performance improvement, and focused review of the chief geriatric physician’s care. 

The objective of the FY 2025 Federal Information Security Modernization Act (FISMA) audit was to determine whether the U.S. Department of Education’s (Department) overall information technology (IT) security program and practices are effective as they relate to Federal information security requirements. To determine the effectiveness of the Department’s information security program, the audit team utilized the FY 2025 Inspector General FISMA reporting metrics, which required that an independent assessor evaluate core and supplemental reporting metrics identified by the Office of Management and Budget. To properly conclude on the effectiveness of the Department’s information security program and practices, a rotational strategy was used to select five in-scope systems not evaluated in the previous year’s audit. Overall, the audit team found that the Department’s information security programs and practices were effective supporting the five in-scope systems, as nine out of 10 FISMA domains were effective, and one FISMA domain was not effective. Additionally, a total of 16 conditions were identified and 5 recommendations were made across the ten FISMA domains indicating potential areas of improvement for the Department. 

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA New Mexico Healthcare System (facility) to assess allegations and concerns related to the care of a patient who was labeled as ineligible for care and senior leaders’ associated response.

In early 2024, the patient was admitted to the facility and applied for healthcare benefits. The patient inaccurately reported income on the application, and benefits were declined. Social work staff, aware of the inaccuracies, did not ensure information was corrected. Additionally, staff attempted to arrange post-hospital services only available to eligible patients and failed to coordinate follow-up care after discharge.

In spring 2024, the patient returned to the facility, was admitted, and then discharged the same day due to being labeled as ineligible for care. The OIG did not substantiate that a podiatrist was forced to discharge the patient. However, knowledge and communication deficits contributed to the following deficiencies:
•    The emergency department provider did not follow stated practice to transfer or admit the patient. 
•    Staff missed another opportunity to update the patient’s financial information.
•    The podiatrist did not seek Chief of Staff approval to continue care at the facility or transfer the patient to a community hospital.
•    Staff did not provide an adequate discharge plan. Instead, the patient was left alone on a bench to await ambulance transport and did not receive written discharge instructions.
•    The podiatrist did not contact the community hospital to share information.
•    The nurse officer of the day failed to address a nurse’s attempt to escalate concerns.

The OIG found senior leaders did not effectively use root cause analysis processes or apply High Reliability Organization principles to assess the spring 2024 discharge. First-year podiatry residents were not supervised according to Veterans Health Administration policy.

The OIG made 15 recommendations to the Facility Director.