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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Consumer Product Safety Commission
Audit of the CPSC’s FISMA Implementation for FY 2025
The U.S. Consumer Product Safety Commission (CPSC) OIG retained Williams, Adley, & Co.-DC LLP (Williams Adley, we), an independent public accounting firm, to perform the independent assessment of the CPSC’s implementation of FISMA for FY 2025 and to determine the effectiveness of its information security program. This report documents the results of the OIG’s FISMA evaluation. Specifically, we assessed the CPSC’s compliance with the annual Inspector General (IG) FISMA reporting metrics set forth by the DHS and OMB.
Audit of the Office of Justice Programs Office of Juvenile Justice and Delinquency Prevention National Mentoring Programs Grants Awarded to YouthBuild Global, Inc., Roxbury, Massachusetts
Close-Out Audit of the Schedule of Expenditures of Peace Players International, Champions for Peace Program in West Bank and Gaza, Cooperative Agreement 72029420CA00004, October 1, 2022, to September 28, 2023
This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Central Ohio Health Care System in Columbus.
This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
The OIG issued three recommendations for VA to correct identified deficiencies in three domains: 1. Culture • Standardized process for service-level communication 2. Environment of care • Clean patient areas and intact walls 3. Veteran-centered safety net • Housing and Urban Development–Veterans Affairs Supportive Housing program resources
The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) in Las Vegas to analyze facility leaders’ response to allegations that a dental hygienist failed to follow Veterans Health Administration and facility policies and provide quality care. The OIG determined that supervisors did not ensure the correction of patient safety concerns related to the dental hygienist’s practice after having knowledge of the repeated concerns for approximately two years.
A supervisor requested a factfinding, which substantiated the dental hygienist falsified a patient’s electronic health record; however, the falsification went unaddressed. The factfinding was not completed timely and, although requested, a review of two medication storage violations was not included. Additionally, a supervisor considered but did not implement a performance improvement plan to address repeated clinical practice concerns and infection control violations.
Due to conflicting recollections, the OIG was unable to determine whether a supervisor recommended a comprehensive review of the dental hygienist’s care to the credentialing and privileging manager, which is a step in the state licensing board (SLB) reporting process. Also, on the provider exit review form, a supervisor did not accurately reflect clinical care concerns regarding the dental hygienist. An accurate form would have prompted initiation of the SLB reporting process. Further, supervisors did not ensure that patient safety reports were submitted through the Joint Patient Safety Reporting system as required.
The OIG determined that the Chief of Staff (COS) did not consider a management review of the dental hygienist’s care after receiving a recommendation from a risk manager to conduct a management review. The COS also did not effectively utilize high reliability organization principles to become aware of the full extent of patient safety concerns regarding the dental hygienist.
The OIG made eight recommendations to the Facility Director.
As of February 2025, NASA had allocated over $26 billion in government property to contractors in support of six Artemis programs. Although NASA has policies in place to manage its government property, the Agency can strengthen its oversight by ensuring consistent application of those policies to decrease the risk of unnecessary costs and potential loss, theft, misuse, or destruction of government property.