Federal Reports

The VA Office of Inspector General (OIG) conducted this healthcare inspection to respond to allegations related to inadequate nurse staffing and nurse-to-patient ratios in the Critical Care Unit (CCU) purportedly resulting in poor quality of care, which included the development of pressure ulcers, inadequate cardiac and respiratory care, and intravenous medication management failures. Lack of consistent documentation prevented the OIG from determining whether nurse staffing contributed to many of the conditions outlined in the allegations. The CCU daily nurse assignment sheets did not consistently document which bed a patient occupied or the nurse-to-patient assignment. The OIG identified noncompliant facility practices and other deficits that contributed to care management challenges and increased risk for poor clinical outcomes. The facility failed to designate a committee, required by Veterans Health Administration (VHA) and its own policies, to develop, implement, monitor, and evaluate the Pressure Ulcer Prevention Program. Facility staff with relevant wound care knowledge met periodically as the Skin and Wound Care Committee and provided pressure injury data to other committees, but there was limited evidence of analysis, action, or follow-up. Additionally, some CCU nurses did not know about the facility policy requirement to initiate wound care consults for patients at high risk for pressure injuries. Facility and tele-intensive care unit (ICU) staff also did not immediately recognize and respond to a life-threatening arrhythmia, which may have contributed to a patient’s death. Other OIG-identified deficits related to respiratory care, sitter availability, and medication management. The OIG made recommendations to the Facility Director regarding compliance with VHA and local requirements for pressure injury prevention and management including nursing documentation. Other recommendations focused on tele-ICU and cardiac monitoring, the respiratory care for a specific patient, processes for securing sitters when ordered, and CCU nursing staff assignment practices.

This report transmits the results of the Federal Election Commission (FEC) Office of Inspector General (OIG) fiscal year (FY) 2019 review of the FEC’s compliance with the Improper Payments Information Act of 2002 (IPIA), as amended. Our review concluded that FEC is compliant with the improper payment requirements2 for FY 2019.

Our objective was to report internal control weaknesses, noncompliance issues, and unallowable costs identified in the single audit to the Social Security Administration (SSA) for resolution action.

Our objective was to report internal control weaknesses, noncompliance issues, and unallowable costs identified in the single audit to the Social Security Administration (SSA) for resolution action.

What We Looked AtAfter the fatal collapse of a pedestrian bridge at Florida International University (FIU) on March 15, 2018, the Secretary of Transportation and the Ranking Member of the Senate Committee on Commerce, Science, and Transportation asked us to review DOT’s oversight role in the FIU project. In July 2018, citing safety concerns, three Florida members of the House of Representatives asked us to examine DOT’s role in a project to improve Interstate 4 in Orlando. Within DOT, the Federal Highway Administration (FHWA) had primary responsibility for both projects and designated them for greater oversight under its risk-based stewardship and oversight framework. Thus, we initiated this audit to assess FHWA’s oversight of transportation projects in Florida, with a focus on the FIU and I-4 projects. What We FoundWhile FHWA has general guidance for implementing its framework for risk-based project involvement Agency-wide, it does not clearly explain how FHWA Divisions should assess and document project risks, use experts to evaluate technical risks, or help Division staff determine when greater oversight is warranted. The lack of a fully developed process could reduce the effectiveness of FHWA’s risk-based oversight for Florida projects. In addition, FHWA’s guidance and the Florida Division’s process lack details to help staff develop effective risk-based project oversight plans. For example, the Florida Division does not always clearly define its role in the plans or their associated documentation. As a result, FHWA’s risk-based project oversight plans do not provide a complete record of the Agency’s involvement or help management determine if that involvement is adding value—a core principle of the FHWA framework. Finally, FHWA Headquarters lacks a process for monitoring and evaluating the impact of its risk-based project involvement, which limits the Agency’s ability to determine if it is achieving its goal—to improve projects and make efficient and targeted use of its limited resources. Our RecommendationsWe made eight recommendations to improve FHWA’s guidance and the Florida Division’s process for risk-based project involvement. FHWA concurred with six recommendations and partially concurred with two. We consider all eight recommendations resolved but open pending completion of planned actions.