Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding community care consult appointment scheduling practices and delays for patients with serious health conditions who received community care at the VA Western New York Healthcare System (system) in Buffalo.The OIG substantiated community care staff’s delays in scheduling patients’ radiation therapy and neurosurgery appointments resulted in delays in patient care, and in some cases caused or increased the risk of patient harm. The OIG found that a delay in scheduling, and eventual cancellation of, community care radiation therapy to treat a patient’s cancer-related pain resulted in progressive, debilitative pain. Although late in the course of the disease, receiving radiation therapy may have decreased the pain and improved the quality of life in the patient’s final months. System leaders failed to conduct an institutional disclosure to the patient’s family.The OIG determined system and community care leaders failed to resolve significant community care scheduling delays for patients with serious health conditions, despite patient advocacy by providers and community care staff. The OIG found leaders relied on inaccurate assurances from system community care leaders that urgent, high-risk patient care consults were reviewed and prioritized, even when alerts to patient concerns continued. System and community care leaders’ lack of action was contrary to high reliability organization principles and values, as they failed to consistently focus on patients, get to the root cause of concerns, and predict and eliminate risk before causing patient harm.The OIG made two recommendations to the VISN Director related to system leaders’ response to patient concerns, and oversight of community care practices; and two recommendations to the System Director related to the establishment of community care policies in alignment with VHA community care standards, and the disclosure of an adverse event.

At the request of Senator Charles Grassley, our office reviewed the U.S. International Development Finance Corporation’s (DFC) nondisclosure policies, forms, agreements, and related documents to ensure conformity with the anti-gag provision of the Whistleblower Protection Enhancement Act of 2012(WPEA).

Objectives: To determine whether—for a select group of employees—the Social Security Administration: (1) complied with its policies and procedures over employees’ premium pay hours and (2) paid employees the proper premium pay amounts.

The Department of Homeland Security has technology that enables identification and sharing of emerging threat information, but DHS partners did not always use this technology to obtain threat information. DHS has various technological methods for maintaining real-time situational awareness and identifying threat information, such as the Office of Homeland Security Situational Awareness’ media monitoring and a virtual situation room. DHS shares this information via its Homeland Security Information Network (HSIN). However, DHS partners often did not leverage HSIN for information sharing. According to the Office of the Chief Information Officer’s data, more than half of the 55,609 active HSIN account holders did not log into HSIN between March 22 and September 15, 2023.

The OIG inspection team inspected Plant Operations processes and procedures used to measure performance. Specifically, the OIG:1. Identified what metrics Plant Operations uses.2. Determined how Plant Operations incorporates identifying and reporting metrics into its processes and procedures.