Federal Reports

The OIG inspection team assessed whether the Superintendent of Documents (SuDoc) is meeting the intent of 44 United States Code (U.S.C.) Section 1909 to “make firsthand investigation of conditions for which need is indicated” with the Public Access Assessments (PAA) of the Federal Depository Libraries (FDL).

VA medical facilities use automated dispensing cabinets to help manage medication inventory and allow clinical staff to dispense medications to patients near the point of care. The OIG conducted this national review to evaluate whether controls at VHA medical facilities ensure accountability over high-risk medications when clinical staff remove them from these cabinets using generic information, such as codes or nonpatient information.

The OIG estimated that in fiscal year 2024, VA medical facilities could not fully account for 46 percent of medications removed with generic information from cabinet A (one of two types of cabinets reviewed, called A and B in the report). Facilities had the most issues tracing propofol to specific patients. Cabinet B transactions could not be projected due to data limitations, but these transactions may also be at risk of not being traceable to a patient. These issues occurred because medical facilities’ standard operating procedures and local policies did not address monitoring of medication removals from cabinets using generic information. Some staff reported using generic information out of convenience or to be more efficient.

The OIG reviewed 40 transactions in which staff removed controlled substances using generic information and found one instance in which a facility could not trace a controlled substance to a specific patient. VHA policy does not prohibit using cabinets to store controlled substances, but it does require facilities to maintain full accountability over them through an electronic record that tracks the medication’s removal from a cabinet to its final dispensation. Removing medications without using a patient’s name increases the risk of drug diversion, so this practice should be closely monitored.

VHA concurred with the OIG’s three recommendations to enhance local guidance on, compliance with, and monitoring of these transactions.
 

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General conducted this audit to determine to what extent the EPA National Center for Radiation Field Operations, or NCRFO, has the capability—including appropriate management and internal control, resources, and staff qualifications—to successfully fulfill its roles and responsibilities in preparing for and responding to radiological incidents. 

Summary of Findings

We found that the NCRFO needs to take steps to improve its preparedness to respond to radiological emergencies. While the NCRFO successfully conducted nonemergency responses, such as site assessments, we found that it was not fully prepared for the one emergency response it conducted during the period we reviewed.

This report provides the results of Objective 1, in which we determined whether the State of Michigan used FNS SNAP administrative funds to provide benefits to participants.

The OIG conducted a healthcare inspection to assess the quality of care provided to a patient while hospitalized at the Overton Brooks VA Medical Center (facility). The OIG also identified concerns with a quality review completed after facility leaders became aware of staff’s mismanagement of a patient’s distressed behaviors.

The OIG found deficiencies with the clinical management of the patient while hospitalized. Deficiencies included a physician who lacked a complete understanding of the patient’s diagnosis and clinical response to a medication prior to discontinuing the medication. Further, facility staff mismanaged the patient’s distressed behaviors. Specifically, staff did not: (1) implement one-to-one observation according to facility policy, (2) activate a behavioral patient record flag (an established safety tool for distressed behaviors), or (3) use the electronic health record as a communication tool between disciplines, according to Veterans Health Administration (VHA) policy.

The Facility Director chartered a root cause analysis (RCA); however, the RCA team’s application of the RCA process did not align with VHA requirements. The RCA team’s failure to follow VHA-required guidelines for the composition and the execution of RCA steps and the RCA’s timeliness affected the reliability of the RCA team’s assessment and conclusion. This finding was similar to one published in an April 2025 VA OIG report on this facility.

The Facility Director concurred with the five recommendations the OIG made related to a comprehensive review of the patient’s hospitalization, obtainment of outside medical records, adherence to one-to-one observation policy, interim behavioral patient record flag processes, and accurate documentation of behavioral events.

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This report summarizes the results of Sikich’s independent evaluation and contains ten new recommendations that will assist the agency in improving the effectiveness of its information security and its privacy programs and practices. NCUA management concurred with and has identified corrective actions to address the recommendations.