Federal Reports

In November 2021, Congress passed the VA Transparency & Trust Act of 2021 (Transparency Act) to provide oversight of VA’s spending of COVID-19–related emergency relief funding, including funding related to the Families First Coronavirus Response Act (FFCRA), Coronavirus Aid, Relief, and Economic Security (CARES) Act, and American Rescue Plan (ARP) Act of 2021. To comply, VA must provide a detailed plan to Congress outlining its intent and justification for obligating and expending funds covered by the act. Additionally, the Transparency Act requires VA to submit biweekly reports to Congress detailing its obligations, expenditures, and planned uses, as well as justification for any deviation from the plan. The act also requires the VA OIG to submit semiannual reports comparing how VA is obligating and expending covered funds to the planned obligations and expenditures. In this fifth report, the OIG found that VA’s last biweekly report was dated June 6, 2023; VA stated it received approval from Congress to deviate from the biweekly reporting requirement but has not been able to provide documentation to support this statement. VA’s reported obligations through the fourth quarter of fiscal year 2023 generally aligned with the ARP Act spend plan obligation schedule with few exceptions. Deviations to the spend plan did not affect VA’s compliance with the Transparency Act. However, the OIG found that VA’s lack of reporting does not provide sufficient documentation and precludes Congress and other external parties from determining if funds were properly obligated and expended as required.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated an allegation that College Possible staff and an AmeriCorps member were lobbying at the state capitol in Olympia, WA. AmeriCorps OIG’s investigation substantiated the allegation, and confirmed that only one member was in attendance and the lobbying activity was limited to one day. AmeriCorps OIG referred the matter to AmeriCorps State and National (ASN) and recommended it disallow the member’s service hours and a staff member’s hours that had been charged as matching expenditures for the date of the lobbying activity. AmeriCorps OIG also recommended that ASN provide additional training to College Possible on prohibited activities.

In March 2023, while conducting an audit of the Denver Logistics Center (DLC), the OIG found an employee recreation group was auctioning items that VA purchasers had requested through free offers associated with supply orders that met a minimum-dollar threshold. DLC staff auction winners took the items for personal use, and the proceeds were used to fund staff social events. The OIG initiated this administrative investigation to examine possible misconduct by VA senior leaders responsible for maintaining ethical procurement practices.DLC purchasing agents claimed free items for 32 purchases from February 2021 through May 2023. The employee recreation group then sold the items to staff through silent auctions. Under federal law, the items were government property because they were part of a purchase made by VA. Federal ethics regulations state, “employee[s] ha[ve] a duty to protect and conserve Government property and shall not use such property, or allow its use, for other than authorized purposes.” DLC leaders and staff had taken related VA ethics and purchase card training, which explained management of government property, ethical restraints on receiving free incentives, and purchase card prohibitions; however, no one at the DLC appeared to have questioned the propriety of the auctions.The OIG found the purchases associated with the free items constituted waste. Contrary to VA policy, which requires every effort be made to use government-wide or agency contracts, the DLC purchased these items without considering a preestablished government contract. The DLC director halted the auctions and the acceptance of free merchandise in June 2023. VA concurred with the OIG’s six recommendations that include a full accounting of losses and recoveries, enhanced guidance and training, and taking any other needed administrative actions. VA was also alerted to 168 other facilities that appeared to be receiving free incentives for further examination.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Edward Hines, Jr. VA Hospital (facility) in Hines, Illinois, to assess an allegation that deficient quality of care resulted in a patient’s foot amputation.The patient told facility primary care staff about falling at home while wearing VA-issued diabetic shoes. At the time of the fall, the patient had temporarily stopped taking anticoagulation medication, as instructed, for a procedure. The patient told clinical staff of symptoms consistent with an arterial occlusion 11 and 12 days after the fall; staff referred the patient to an emergency department. The patient elected to wait and go to the facility for diagnostic testing, and later underwent a foot amputation due to an arterial occlusion. The facility’s vascular surgeon told the OIG that the arterial occlusion may have been caused when the patient stopped anticoagulation medication (prior to a bleeding-risk procedure) or possibly due to the fall.Pharmacy staff managed the patient’s anticoagulation medication in accordance with Veterans Integrated Service Network and facility guidance.The day of the fall, a podiatrist saw the patient for an annual evaluation and gave instructions to wear the previously provided VA-issued shoes, a type of shoe with known challenges related to fit and heel slippage. The OIG determined that the podiatrist missed an opportunity to provide reeducation or refit the patient with new VA-issued shoes.The patient attributed the fall to the shoes and reported concerns to the facility’s patient advocate. The OIG found that the patient advocate did not consult with the facility’s patient safety staff, as required, after receiving concerns from the patient alleging facility staff’s negligence led to the amputation.The OIG made two recommendations related to consulting with patient safety and refitting and reeducating patients on VA-issued shoes.