Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care at the VA Texas Valley Coastal Bend Health Care System, covering leadership, organizational risks, and key processes associated with promoting quality care. Areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s executive leadership team appeared relatively stable even though three of the four positions were permanently filled less than six months before the OIG’s site visit. The executive leaders had served in an acting capacity in their current position prior to being selected permanently. Employees and patients seem generally satisfied with the leadership and care provided. The facility leaders appeared actively engaged and supported efforts to improve and maintain patient safety, quality care, and other positive outcomes. The OIG’s review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leadership team was knowledgeable within their scope of responsibility about selected SAIL metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “2-star” quality rating. The OIG issued 11 recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Weekly electrical system inspections (3) Controlled Substances Inspections • Reconciliation of dispensing and return of stock (repeat finding) • Controlled substances order verifications (4) Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Patient/caregiver understanding of education • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership

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What We Looked AtThis report presents the results of our quality control review (QCR) of an audit of the Department of Transportation's (DOT) information security program and practices. The Federal Information Security Modernization Act of 2014 (FISMA) requires agencies to develop, implement, and document agencywide information security programs and practices. The act also requires agencies to have annual independent reviews to determine the effectiveness of their programs, and report the results of these reviews to the Office of Management and Budget (OMB). To meet this requirement, we contracted with CliftonLarsonAllen LLP (CLA) to conduct this audit subject to our oversight. The audit objective was to determine the effectiveness of DOT's information security program and practices in five function areas--Identify, Protect, Detect, Respond, and Recover.What We FoundWe performed a QCR of CLA's report and related documentation. Our QCR disclosed no instances in which CLA did not comply, in all material respects, with generally accepted Government auditing standards.RecommendationsDOT concurs with 1 of CLA's 14 recommendations and partially concurs with the remaining 13 recommendations. ClA considers recommendations 1, 2, 4, 8, 9, 10, 11, and 12 resolved but open pending completion of planned actions. CLA considers recommendations 3, 5, 6, 7, 13, and 14 open and unresolved.

GAO's Inspector General submitted this report to the Comptroller General of the United States in accordance with Section 5 of the Government Accountability Office Act of 2008. The report summarizes the activities of the Office of Inspector General (OIG) for the six-month reporting period ending September 30, 2019. During the reporting period, the OIG completed three audits and issued reports thereon. The OIG closed 6 investigations and opened 3 new investigations. In addition, the OIG processed 73 hotline complaints, many of which were referred to other OIGs for action because the matters involved were within their jurisdictions. The OIG continues to focus on GAO management challenge areas—including human capital management and information technology. The OIG remained active in the GAO and OIG communities by briefing new GAO employees on its audit and investigative missions, and participating in committees and working groups of the Council of Inspectors General on Integrity and Efficiency. Details of these activities and other accomplishments are provided in the report.