Federal Reports

The VA Office of Inspector General (OIG) conducted a review to assess the merits of a January 2022 hotline allegation concerning inappropriate edits to community care referrals, known as consults, at the Puget Sound VA Health Care System in Seattle, Washington. The VA MISSION Act of 2018 allows veterans to receive care from non-VA healthcare providers in their area (known as community care) under certain circumstances. Community care schedulers are required to notify veterans of their eligibility, including if veterans are eligible to make such appointments themselves, called self-scheduling.The complainant made three allegations: (1) a leader at the Puget Sound facility inappropriately edited community care consults to reduce backlog; (2) a community care scheduler enrolled patients in self-scheduling without asking them; (3) and facility leaders encouraged staff to inappropriately edit consults to reduce backlog and improve wait times.Though a facility leader made approximately 5,300 edits to about 4,400 community care consults between June and December 2021, the review team did not substantiate that the edits were inappropriate and intended to improperly reduce backlog. Records show a scheduler registered veterans for self-scheduling on 1,158 consults during a two-week period in June 2021, but evidence was insufficient to substantiate whether the scheduler spoke with veterans or sent them letters before converting them to self-scheduling. A requirement to document notification was not in place at the time of the scheduler’s actions, and the team could not interview the scheduler, who left VA employment before an interview could take place. The team reviewed more than 3,800 VA email records and interviewed leaders and staff but found no evidence that facility leaders encouraged staff to inappropriately edit community care consults to reduce backlog and improve wait time metrics.Given the lack of substantiation, the OIG made no recommendations to VA for corrective actions.

The VA Office of Inspector General (OIG) contracted with the independent public accounting firm CliftonLarsonAllen LLP (CLA) to audit VA’s financial statements as of September 30, 2022 and 2021, and for the fiscal years then ended. CLA provided an unmodified opinion on VA’s financial statements for fiscal year (FY) 2022 and FY 2021. CLA did, however, note material weaknesses and significant deficiencies in internal control and instances of noncompliance with laws and regulations.Regarding internal control, CLA identified three material weaknesses. A material weakness is a deficiency, or combination of deficiencies, in internal control over financial reporting such that there is a reasonable possibility that a material misstatement of the entity’s financial statements will not be prevented or detected and corrected on a timely basis.CLA also identified two significant deficiencies. A significant deficiency is a deficiency, or a combination of deficiencies, in internal control over financial reporting that is less severe than a material weakness, yet important enough to merit attention by those charged with governance. CLA is responsible for the attached audit report dated November 15, 2022, and the conclusions expressed in the report. The OIG does not express opinions on VA’s financial statements, internal control, or compliance with FFMIA, nor does the OIG express conclusions on VA’s compliance with laws and regulations. The independent auditors will follow up on these internal control and compliance findings and evaluate the adequacy of corrective actions taken during the FY 2023 audit of VA’s financial statements.

ED OIG SAR 85 Final 508

This report highlights and summarizes significant oversight work performed during this period that have strengthened the Denali Commission's programs and operations for the period ending September 30, 2022.

This report is a summary of the Pandemic Response Accountability Committee’s accomplishments between April 1, 2022, and September 30, 2022.

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient settings of the Louisville VA Medical Center and associated outpatient clinics in Indiana and Kentucky. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center prevention initiatives)The OIG issued five recommendations for improvement in three areas:1. Quality, safety, and value• Executive Leadership Council processes• Peer review processes2. Medical staff privileging• Focused Professional Practice Evaluations3. Environment of care• Environmental cleanliness