Federal Reports

The VA Office of Inspector General (OIG) conducted an inspection to evaluate facility oversight and leaders’ response to a pathologist’s practice at the facility. The OIG found the Pathology and Laboratory Medicine Chief (Chief) followed VHA policy and performed a quality review of surgical pathology cases and reported the pathologist’s initial misdiagnosis. Facility leaders ensured the required comprehensive clinical care reviews were conducted, resulting in the discovery of 10 additional misdiagnoses. The pathologist also misdiagnosed a skin biopsy. The Chief followed Veterans Health Administration (VHA) policy for secondary reviews of the misdiagnoses, completed supplemental reports, and documented provider notification. The OIG found no documentation that providers informed three patients of their misdiagnoses. The OIG learned one patient experienced an adverse clinical outcome and did not have any documented disclosures. Also, facility staff and leaders did not report any of the misdiagnoses as adverse events. Facility leaders summarily suspended the pathologist; however, the OIG found no documentation renewing the suspension. The Facility Director then terminated the pathologist. The pathologist appealed the termination through the VHA Disciplinary Appeals Board, which recommended a reinstatement. The pathologist was reinstated, and clinical privileges were restored. Facility leaders did not comply with VHA’s mandated privileging processes and were unaware of who was responsible for state licensing board reporting. Quarterly retrospective reviews of all pathology reports exceeded the 10 percent standard; however, the Chief and staff pathologists did not consistently review 10 percent of each pathologist’s cases. The Chief and staff pathologists reviewed 9.4 percent of the pathologist’s cases, below the 10 percent requirement. The OIG made 10 recommendations related to test results, disclosure and reporting of adverse events, issue briefs, the summary suspension process, the credentialing and privileging process, state licensing board reporting, and quality reviews of the pathologists’ work.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Illiana Health Care System and multiple outpatient clinics in Illinois. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leadership team positions were filled more than six months prior to the on-site visit. Survey results revealed opportunities for the Associate Director to improve employee satisfaction and for the Chief of Staff and Associate Director Patient Care Services to improve staff feelings of “moral distress” at work. Patient experience survey data indicated that patients appeared satisfied with their care. The OIG’s review of the system’s accreditation findings did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scopes of responsibilities about selected Strategic Analytics for Improvement and Learning data and should continue to take action to sustain and improve performance.

This report presents the results of our audit of all stamp and cash inventories at six postal units in Chicago, IL. These offices were located in the Chicago District of the Great Lakes Area. We conducted this audit in response to concerns raised by the U.S. Postal Inspection Service of potentially lost stamps, cash, and money orders due to looting of offices during protests and riots from May 29 through June 1, 2020. The six postal units audited were Englewood, Station K, Wicker Park Retail Store, Wicker Park Carrier Annex, Ogden Park, and Henry W. McGee. All six postal units had thefts of mail and parcels. One unit had theft of stamps and cash. One unit did not have any stamp or cash inventory.

Our objective was to evaluate the performance of the U.S. Postal Service’s Small Package Sorting System (SPSS) machines.The continued growth of eCommerce and the package delivery market provides opportunities for the Postal Service to increase revenue. The Postal Service has directed resources and management attention toward building a world-class package platform to compete and gain business in the package delivery market. Part of this strategy includes purchasing package processing machines such as the SPSS to improve efficiency and meet demand.

Congress has expressed concerns about the safety and well-being of children in foster care. Additionally, in a recent series of audits of State-monitored child care facilities in various States, we found that the majority of child care providers had instances of potentially hazardous conditions and noncompliance with State health and safety requirements, including employee background record check requirements. To determine whether similar vulnerabilities exist in foster care group homes, we performed this audit in Kansas. Allegations of neglect and abuse at some foster care group homes in Kansas were the subject of a number of reports in the media, both before and during our audit.

The OIG investigated allegations that a U.S. Bureau of Reclamation (BOR) project management specialist illegally diverted water from a BOR canal to a private ranch. Our investigation confirmed the project management specialist approved the water diversion, but we did not find evidence the project management specialist received any personal benefit, financial or otherwise, as a result. The project management specialist said they approved the water diversion because they were trying to solve the ranch owner’s concern that construction in the area had blocked flood-water overflow from coming onto the ranch owner’s property. The project management specialist further said they were concerned that the ranch owner would terminate an agreement that allowed the BOR to operate a pump station—which the BOR uses to protect endangered species in the area by pumping water to dry areas—on the ranch owner’s property because the terms of the agreement allowed the ranch owner to terminate the agreement if the ranch owner believed the BOR impeded any of their projects.We further found the project management specialist circumvented engineering and environmental approval by funding the project through an existing operations and maintenance contract instead of a new contract, which would have triggered the BOR’s review and approval process. The project management specialist said they believed the project was within the scope of work of the existing contract and did not seek approval before authorizing the water diversion.

What We Looked AtThe National Airspace System (NAS) serves over 44,000 flights a day with over 5,000 aircraft in the sky at peak times. Critical to the NAS's operations are the Federal Aviation Administration's (FAA) 20 Air Route Traffic Control Centers (Centers) that manage high-altitude air traffic. These Centers are equipped with the En Route Automation Modernization (ERAM) system to manage and control high-altitude operations and provide infrastructure for new systems such as high-altitude data link communications for FAA's Next Generation Air Transportation System (NextGen). In response to requests from the Senate Committee on Commerce, Science, and Transportation and the House Committee on Transportation and Infrastructure and its Aviation Subcommittee, we conducted this audit. Our objectives were to (1) evaluate FAA's planned upgrades to ERAM and (2) assess ERAM's ability to support key NextGen capabilities.What We FoundFAA is making a significant investment to sustain and enhance ERAM's hardware and software at the Centers. Over 6 years, the Agency will replace ERAM's original computer hardware and modernize ERAM's software to allow system improvements and new capabilities. Once these upgrades are complete, ERAM will essentially be a new system with enhanced capabilities. FAA plans to continue to add capabilities and keep the system up to date. FAA has re-categorized ERAM from a moderate to a high-impact system but has not yet determined what security controls the system will require as a high-impact system.FAA has integrated NextGen capabilities into ERAM but faces challenges realizing full benefits for airspace users. FAA considers ERAM foundational to many NextGen systems, including the Automatic Dependent Surveillance--Broadcast (ADS-B) system, performance based navigation (PBN), and data communications (DataComm). The Agency has integrated ADS-B and PBN with ERAM but has encountered delays implementing DataComm's high-altitude services due to the impact of the Federal Government shutdown in late 2018 and early 2019, air-to-ground network problems, and other issues. Because FAA will develop new procedures and training for controllers and pilots for these capabilities, it is uncertain when these enhancements and NextGen capabilities will provide full benefits for airspace users.RecommendationsWe made one recommendation to help FAA improve its efforts to upgrade ERAM to support NextGen capabilities. FAA concurred with our recommendation.