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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Department of Labor
ETA Needs to Improve Oversight of the Disaster Dislocated Worker Grants
Investigative Summary: Findings of Misconduct by an Assistant United States Attorney for Conduct Prejudicial to the Government and Misuse of Government Property
The Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the U.S. Nuclear Regulatory Commission in Fiscal Year 2025
The Reports Consolidation Act of 2000 (Public Law 106-531) requires the OIG to annually summarize what it considers to be the most serious management and performance challenges facing the U.S. Nuclear Regulatory Commission. The Act also requires the OIG to briefly assess the agency’s progress in addressing those challenges.
Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the Arizona Department of Public Safety to the Jewish Family and Children's Services of Southern Arizona, Inc. Tucson, Arizona
Heart Transplant Program Review: Facility Leaders Failed to Ensure a Culture of Safety and the Section Chief Engaged in Unprofessional Conduct at the Richmond VA Medical Center in Virginia
The VA Office of Inspector General (OIG) conducted a healthcare inspection to review allegations regarding the heart transplant program and the performance and behavior of the cardiothoracic section chief (section chief). The OIG also reviewed the temporary inactivation of the heart transplant program and factors associated with reactivation, and Veterans Integrated Service Network (VISN) and facility leaders’ responses to staff concerns about the heart transplant program.
The OIG did not substantiate that the section chief’s surgical patient outcomes, including morbidity and mortality rates, and the facility’s readmission rates statistically varied from national averages to warrant further assessment by the National Surgery Office.
The OIG was unable to determine whether the section chief had “incredibly long” cardiopulmonary bypass times and was not able to draw a conclusion regarding current versus historical cardiopulmonary bypass times for the section chief. The OIG noted facility staff performed a low volume of transplants, which may contribute to variations in outcomes.
The OIG substantiated the section chief repeatedly exhibited unprofessional conduct toward staff, and determined facility and surgical leaders failed to create a culture of safety to ensure staff felt comfortable reporting concerns.
The OIG found VISN leaders failed to ensure a timely quality of care review of cardiothoracic cases; however, the VISN Chief Medical Officer identified further concerns in the heart transplant program that were addressed promptly.
The OIG made two recommendations to the Under Secretary for Health related to a comprehensive review of the transplant program and oversight of quality measures; one recommendation to the VISN Director regarding completion of facility leaders’ requests for clinical care reviews; and three recommendations to the Facility Director including a clinical care review, a review of the section chief’s conduct, and a review of staff’s concerns and development of a culture of safety.
Massachusetts Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety and Emergency Preparedness
