Federal Reports

Strengthening adherence to EPA discovery policies and procedures can promote efficient and effective criminal prosecution.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) to assess allegations that facility staff delayed ordering medications following a patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide.The OIG found a community care nurse provided inadequate care coordination, including delayed and omitted clinical documentation. The OIG determined this limited primary care staff's ability to provide care in advance of and after discharge from the community hospital.Primary care staff care coordination process deficiencies contributed to a delay in the patient’s discharge medications. Primary care staff failed to provide health education to the patient about how to obtain the prescribed medications and did not provide same day access to address a lapse in cardiac medication. Additionally, the primary care provider failed to order the patient’s discharge medications.The OIG determined that a VISN physician lacked critical clinical information, did not conduct a complete medication reconciliation, and lacked knowledge of the process to order the patient’s anticoagulant medication, contributing to the delay in ordering medication.The OIG found primary care staff failed to notify suicide prevention staff of the patient’s death by suicide and failed to complete a suicide behavior overdose report immediately upon notification. Further a former suicide prevention program manager failed to timely complete the behavioral health autopsy and a family interview tool contact form.The OIG made one recommendation to the VISN Director to review the patient’s care and take actions as warranted and four recommendations to the Facility Director related to community care coordination, primary care, actions required following a patient death by suicide, and to take actions as warranted.

RMA Associates, LLC (RMA), under contract with the Department of Homeland Security Office of Inspector General, concluded that DHS complied with applicable statutes, regulations, and policies governing grants and contracts awarded by means other than full and open competition in fiscal year 2023. During that year, DHS awarded 28 noncompetitive grants worth approximately $17 million and 410 noncompetitive contracts worth approximately $589 million through means other than full and open competition.

In our final report, we reviewed key aspects of the Food and Nutrition Service funding and administration of Pandemic Electronic Benefits Transfer assistance.

We audited the Kentucky Commission on Human Rights’ fair housing complaint intake process. We initiated this audit based on an internal risk assessment of Fair Housing Assistance Program agencies’ challenges. Our audit objectives were to (1) determine the extent to which the Commission processed fair housing inquiries within 30 days and (2) evaluate its reasons for closing fair housing inquiries.We were unable to determine the extent to which the Commission processed fair housing inquiries within 30 days due to a lack of supporting documentation. Also, the Commission could not provide evidence that would have allowed us to determine whether fair housing inquiries were properly closed. In addition, the Commission did not have clarity on what inquiries should be recorded in the U.S. Department of Housing and Urban Development’s (HUD) Enforcement Management System (HEMS) or what type of documents should be recorded in that system to support closure decisions. These conditions occurred because the Commission lacked staffing for its housing intake process, lacked an effective system to track the processing of inquiries, and was not always able to retrieve documents because some emails were lost. Also, the Commission did not have a record retention policy for its intake, and its staff was inadequately trained for recording intake data in HEMS. As a result, the Commission could not consistently provide assurance to its customers that it properly processed and closed inquiries from complainants in a timely manner. If complainants’ alleged discrimination is not addressed properly and in a timely manner, the Commission may not help to stop ongoing discrimination, hold those responsible for their actions, and deter future discrimination.We recommend that HUD’s Deputy Assistant Secretary for Enforcement require the Commission to (1) update its intake policy and procedure to clarify which inquiries are to be recorded in HEMS; (2) develop an internal agency intake training guide, distribute it to all agency housing staff members, and ensure that all intake staff members participate in HUD-approved training related to intake; (3) implement a record retention policy to ensure that decisions on inquiries are sufficiently supported; (4) implement a plan to ensure that it has sufficient staff to meet its obligations under the Fair Housing Assistance Program cooperative agreement; and (5) implement a system to better track the intake and processing of potential fair housing inquiries.