Federal Reports

Restricted release report.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to deficiencies in the Women Veterans Health Program; Quality, Safety and Value (quality management) in patient safety and clinical events leading to resuscitation attempts; and leaders’ responses to recommendations from oversight bodies at the facility. The facility responded appropriately to oversight review recommendations. An insufficient number of designated women’s health primary care providers was assigned and trained to provide gender-specific comprehensive primary care for women veterans at the facility; the length of appointment times was not adjusted as required for unique gender-specific care. Additionally, the Women Veterans Program Manager was not fully engaged and contributed to a failure to identify resources needed for the provision of women veterans’ healthcare. A gynecologist and advanced practice registered nurse shared a licensed vocational nurse to serve as the required chaperone during examinations, impeding simultaneous examinations. Community Care served as a vital women veterans’ health resource; however, the facility did not have a standard operating procedure to track the Community Care results that were administratively closed or reported back to the requesting Veterans Health Administration (VHA) provider. Prolonged vacancies within quality management contributed to deficient performance measurement and evaluation processes. Leaders were not aware of all adverse events requiring potential institutional disclosure and corrective actions to prevent future adverse events were delayed. Facility clinical staff lacked training and an understanding of nationally identified guidelines for conducting patients’ goals of care conversations regarding life-sustaining treatments. Due to a lack of consistent processes, the resuscitation committee did not capture and review all resuscitation attempts nor take corrective actions to identify the causes surrounding these events, as required by VHA policy. The OIG made 18 recommendations related to staffing, appointment times, current and future resources, community care, and quality management processes.

The Office of the Inspector General conducted a review of the Hydro Generation, Central Region (Hydro Central) to identify strengths and risks that could impact Hydro Central’s organizational effectiveness. Our report identified strengths that positively affected the day-to-day activities of Hydro Central personnel. These strengths included (1) organizational alignment, (2) positive interactions within and outside of Hydro Central, (3) effective leadership, and (4) positive ethical culture. However, we also identified risks that could hinder Hydro Central’s effective execution and its continued ability to meet its responsibilities in support of the Power Operations mission. These were comprised of risks related to (1) employee behaviors inconsistent with TVA values in two plant groups, (2) safety concerns due to asset and equipment conditions, and (3) workforce training and staffing.

Our objectives were to determine the accuracy and timeliness of remittances field offices processed via the Social Security Electronic Remittance System (SERS) for beneficiary-related debts. We also determined whether remittances field offices mailed to the Social Security Administration's (SSA) Mid-Atlantic Program Service Center )(MATPSC) should have been processed through SERS.

We found that the CSB was fully compliant with improper payments legislation and guidance during fiscal year 2019.We have amended our previous memorandum dated December 19, 2019, to add a sentence stating that our work was not performed in accordance with generally accepted government auditing standards.

An Amtrak Passenger Conductor in Los Angeles, California, was terminated from employment on January 23, 2020, following the employee’s administrative hearing for violating company policy. Our investigation found that the employee was convicted of a DUI in July 2015 and failed to report the conviction to the company, as required by company policy.

The Government Charge Card Abuse Prevention Act of 2012 requires Inspectors General to report on the implementation of recommendations made to their agencies to address audit findings for travel and purchase cards. Office of Management and Budget (OMB) guidance requires Inspectors General to submit their reports to OMB by January 31 of each year.

The unclassified version of the SAR covers the period from April 1, 2019 through September 30, 2019, and reflects what NSA OIG could release publicly about its work for that reporting period. The OIG issued 14 reports and oversight memoranda during that period, making 232 recommendations to assist the Agency in addressing the findings and deficiencies identified. NSA's management agreed with all OIG recommendations made during this period. The Director of the NSA and Congress previously received the classified version of the SAR in accordance with the IG Act.