Federal Reports

Researchers have estimated that over 200,000 people die each year because of medical errors in hospitals. Learning from those and other, nonfatal events to improve patient safety is the goal of AHRQ's voluntary Patient Safety Organization (PSO) program. Hospitals' descriptions of their experiences with the program provide insight into the program's progress toward facilitating national learning from patient safety events. This review is the first to explore the extent to which hospitals participate in the PSO program and their perspectives on its value and challenges.

Our objective was to determine the amount of Social Security benefits misdirected because of unauthorized my Social Security direct deposit changes through May 2018.

PBGC has made progress in eliminating the unnecessary collection, maintenance, and use of customer social security numbers. However, additional steps are necessary given the volume of legacy documents containing SSNs, the Corporation’s continued acquisition of trusteed plan documents containing SSNs and known risks and limitations in PBGC information systems. We issued four recommendations related to PBGC’s policies and planning for continued reduction in the collection, maintenance and use of Social Security Numbers. PBGC agreed with the recommendations and plans to complete corrective actions by September 30, 2020.

Richland County did not always properly account for and expend Federal funds according to Federal regulations and FEMA guidelines. FEMA did not hold North Dakota accountable for fulfilling its grant management responsibilities, and North Dakota did not adequately manage the FEMA grant by monitoring the County to ensure it complied with applicable regulations and guidelines. The County failed to follow all Federal procurement regulations when awarding about $1.9 million in disaster-related contracts. We recommended that FEMA disallow $1,146,921 in ineligible contract costs and direct North Dakota to work with the County to verify that the County complies with all Federal grant requirements and establishes effective accounting systems. FEMA concurred with our three recommendations for improving County compliance in managing future Federal grants.

In two of the four areas – training and collaboration – Washington’s Emergency Management Division (EMD) and FEMA complied with applicable policies, procedures, and regulations.  In the third functional area – project execution, monitoring and oversight – we did not identify any significant deficiencies.  We found, however, EMD lacked position-specific guidance for all personnel with programmatic responsibilities.  In the last functional area – project and grant closeout – neither EMD nor its subrecipients submitted timely project closeout requests.  In addition, FEMA did not enforce compliance with its own guidance for processing closeouts.  We recommended FEMA ensure EMD complies with its State Administrative Plan by issuing and regularly updating desk manuals.  In addition, we recommended FEMA coordinate with EMD to initiate closeout on behalf of subrecipients for all open, large projects whose period of performance end dates exceed the 90-day regulatory requirement, and submit closeout requests to FEMA for projects exceeding the 180-day requirement.  We made five recommendations to strengthen EMD’s internal controls to improve its oversight of FEMA’s Public Assistance grant program.  FEMA concurred with all five of our recommendations.