Federal Reports

This report presents the results of our audit of the U. S. Postal Service’s oversight of Parcel Select.

The OIG Evaluation office initiated an evaluation to determine whether the U.S. AbilityOne Commission’s 2022-2026 Strategic Plan contained the necessary framework, including specific operational initiatives, objectives, and associated performance measures. This evaluation was conducted to identify elements to consider incorporating in the next iteration of their strategic plan.

Overall, the Commission created a thoughtful and attainable approach to developing a new strategic plan to work toward the goal of modernizing the AbilityOne Program. We found that the Commission’s 2022-2026 Strategic Plan includes all required strategic plan elements according to federal regulations.
The Commission is a non-Chief Financial Officers (CFO) Act agency, and some statutory elements are not required. As a part of this evaluation, the OIG identified that the inclusion of two additional elements would further enhance the effectiveness of the next iteration of the Commission’s strategic plan. Specifically, the Commission potentially missed key learning opportunities for its strategic plan goals, objectives, and measures because it did not conduct evidence building activities or perform its own internal program evaluations. Furthermore, the Commission should incorporate more quantitative measures in the next iteration. Although the Commission has met federal requirements, these additional elements would provide a more comprehensive and evidence-based approach for measuring the progress toward goals and objectives in the AbilityOne program.

The OIG recommended that the AbilityOne Commission meet with Commission members and stakeholders to determine whether (1) incorporating evidence building and (2) program evaluation into its next strategic planning process would help in identifying key    areas of improvement and improve outcomes. The OIG also recommended that the AbilityOne Commission enhance its ability to track and monitor progress and the successful implementation of agency goals, by establishing and incorporating quantitative measures into the 2026-2030 strategic plan.

The VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection at the Tuscaloosa VA Medical Center (facility) in Alabama to evaluate the status of patient safety program deficiencies identified in a 2023 OIG report and Veterans Integrated Service Network (VISN) 7’s oversight of the facility’s patient safety program. Additionally, the inspection evaluated actions taken to address deficiencies in the community living center (CLC) regarding residents at risk for elopement identified in a 2022 OIG report.
In contrast to previous findings, the OIG found that the facility’s patient safety program complied with VA-mandated standards. The OIG’s analysis of facility patient safety data showed the patient safety manager appropriately accepted or rejected event reports; considered significant safety events for root cause analysis; and completed eight annually required patient safety analyses for fiscal year 2023.
While the VISN patient safety officer’s oversight of patient safety programs improved, the OIG identified the need for qualitative analysis of patient safety data, which is essential to assess the impact and effectiveness of VISN patient safety programs and develop effective actions plans.
Facility leaders addressed the deficiencies identified in the 2023 and 2022 OIG reports and determined actions taken by the facility leaders resulted in a facility culture where patient safety has become paramount. The OIG concluded that a commitment to continue to administer a high-quality patient safety program was evident in facility leaders’ actions.
The OIG determined that the facility resolved previous concerns regarding the safety and security of the residents in the CLC as well as implemented a review process to ensure electronic health record documentation for residents at risk for elopement was consistent with facility policy.
The OIG made three recommendations to the VISN Director related to the patient safety officer’s qualitative reviews of patient safety data.