Federal Reports

The OIG assessed the oversight and stewardship of funds and identified opportunities for cost efficiency at the Marion VA Healthcare System in Illinois. The review focused on four areas:1. Use of the Medical/Surgical Prime Vendor-Next Generation program. The program is a collection of contracts that streamlines purchasing and distribution for certain supplies. The team found that the system was unable to fully achieve the program’s cost savings, in part because some items were in short supply during the pandemic or on back order with the prime vendor.2. Purchase card use. The team did not find staff were improperly splitting purchases to stay below the card purchase limits. Moreover, system staff properly maintained supporting documentation for the sampled transactions and considered contracts instead of purchase cards when appropriate. However, the purchase card program coordinator did not always perform required quarterly audits, and oversight on training for cardholders could be strengthened.3. Open obligations. The team found that the system’s fiscal staff did not always review open obligations for goods and services to determine if they were still valid and necessary. This leaves the system vulnerable to the risk that those funds will be not used in the year they were appropriated, as required.4. Pharmacy operations and cost-savings efforts. The review team found the system had a significant gap between actual and expected drug costs when compared with like facilities. However, it achieved a higher inventory turnover rate than VA’s target rate, which helps reduce the cost of storing inventory.The OIG made eight recommendations for improving cost efficiency. The number of recommendations should not be used, however, to gauge the system’s overall financial health. The intent is for system leaders to use these recommendations as a road map for improvement in the areas reviewed.

The Office of the Inspector General conducted a review of Browns Ferry Nuclear Plant (BFN) Chemistry to identify factors that could impact BFN Chemistry’s organizational effectiveness. During the course of our evaluation, we identified behaviors that had a positive impact on BFN Chemistry, including positive relationships between team members and most management. However, we also identified a minimal behavioral risk related to communication with first-line management. In addition, we identified minimal risks to operations that, if unaddressed, could hinder BFN Chemistry’s effectiveness. These risks related to nonfunctioning equipment and perceptions of inadequate staffing.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) in Las Vegas to assess an allegation that the facility failed to diagnose and treat a patient’s cancer. The OIG identified concerns about potential deficiencies in lung cancer screening, prostate cancer surveillance, consult delay, documentation, and the facility’s response to family complaints.The OIG substantiated that providers failed to make a cancer diagnosis and treat the patient’s cancer. Providers did not take steps that would have allowed them to make a diagnosis, including ordering screening tests. In fall 2020, the patient was found to have left lung primary lung cancer with metastasis to brain, liver, and other areas. The patient died three weeks later.The patient had known lung cancer risk factors that warranted annual screening. The OIG did not find evidence beyond 2013 that pulmonology staff followed up, or that after 2017, primary care providers ensured completion of annual screening. Additionally, the OIG determined that primary care providers did not follow up after a radiology finding that a renal nodule had increased in size. The OIG found that after summer 2016, the patient did not have annual testing completed to check for prostate cancer recurrence. The OIG determined that one primary care provider delayed ordering an oncology consult for 25 days, copied and pasted documentation, and did not document an assessment of the patient’s lung nodules, as required. The OIG found that facility staff documented resolution of a family member’s complaint despite not contacting the family.The OIG made five recommendations to the Facility Director related to evaluation of lung cancer screening and follow-up care; follow-up for abnormal radiology findings; surveillance for patients who have undergone prostatectomy; copy and paste practices and documentation; and review of complaint reporting and responding.

The Baltimore Processing and Distribution Center (P&DC) is in the Chesapeake Division of the Eastern processing region and that facility processes letters, flats, and packages. From August 1, 2020, to July 31, 2021, the Baltimore P&DC processed about 1.67 billion mailpieces compared to about 1.74 billion mailpieces during the same period last year — a decrease of about 70 million mailpieces (4 percent). However, during that same period, workhours and overtime at the facility increased by 14.6 and 43.5 percent, respectively.Recently, the OIG audited nine Baltimore delivery units as part of a congressional request to evaluate mail delivery and customer service operations on selected routes. The objective of this separate but related self-initiated audit was to evaluate the efficiency of plant operations at the Baltimore, MD, P&DC. This audit was completed to identify mail processing issues at the Baltimore P&DC that could affect delivery units served by this P&DC.

This final report provides the results of our evaluation of the U.S. Department of Commerce’s (the Department’s) processes for handling hotline complaints referred by the Office of Inspector General (OIG). The objective of our evaluation was to review the Department’s processes for responding to hotline complaint referrals where OIG requests that the Department conduct an inquiry and provide a response detailing its results (also known as H referrals). Overall, we found that the Department lacked an effective process and internal controls over its hotline \ referrals. This report includes recommendations for the Department to implement internal controls for addressing H referrals efficiently and effectively. See appendix A for specific details on our objective, scope, and methodology.

The OCFO cannot provide reasonable assurance that crosscutting risks are identified and mitigated and that Agency resources are directed to the most critical strategic needs.

The U.S. Department of Housing and Urban Development (HUD), Office of Inspector General (OIG), completed an audit to determine whether FHA-insured borrowers properly received the COVID-19-related forbearance.  The Coronavirus Aid, Relief, and Economic Security Act (CARES Act), signed into law on March 27, 2020, provided a mortgage payment forbearance option for all borrowers who suffered a financial hardship due to the COVID-19 national emergency.We found that at least one-third of the nearly 335,000 borrowers who were delinquent on their FHA-insured loans and not on forbearance in November 2020, were either not informed or misinformed about the COVID-19 forbearance.  As a result, these borrowers experiencing a hardship due to COVID-19 did not benefit from the COVID-19 forbearance.  We also found that servicers improperly administered the forbearance for at least one-sixth of the nearly 815,000 borrowers on forbearance plans in November 2020.  Servicers also performed excessive communication and collection efforts for borrowers who were already in forbearance. As a result, these borrowers experienced additional burdens from improperly administered forbearance.We recommend that FHA identify borrowers who are delinquent and did not fully benefit from the COVID-19 forbearance and ensure that information about the CARES Act and COVID-19 forbearance is distributed to these borrowers. We also recommend that FHA review the 21 loans in our statistical sample with improperly administered forbearance to ensure that the borrowers were assisted by the servicers, if possible, and ensure that these servicers updated their forbearance procedures to prevent future noncompliance; ensure that the issues found during our audit are incorporated into servicing monitoring reviews to deter future noncompliance and prevent potential loss to the FHA fund; and provide additional guidance to the servicers so that they limit their communication and collection efforts for the borrowers in forbearance.