Federal Reports

OIG performed an audit of the National Oceanic and Atmospheric Administration's Pacific Coastal Salmon Recovery Fund Grants awarded to the Washington State Recreation and Conservation Office (RCO). The objectives of our audit were to determine whether RCO (1) claimed allowable, allocable, and reasonable costs, (2) complied with grant terms and conditions, administrative requirements, cost principles, and audit requirements, and (3) met performance requirements of the grants.

An Amtrak Service Engineer resigned from employment on December 20, 2018, following a joint investigation with the Metropolitan Transportation Authority (MTA) OIG which revealed the employee simultaneously worked at both Amtrak and New York’s MTA. The employee failed to disclose his dual employment on Amtrak’s Certificate of Compliance form. When confronted with the investigation’s findings, the employee immediately resigned from the Amtrak.

The OIG investigated multiple allegations of improper hiring, noncompetitive promotions, nepotism, favoritism, and other improper personnel practices by three Bureau of Safety and Environmental Enforcement (BSEE) senior officials.We found that one of the officials violated Federal regulations when he pursued a procurement action to hire an employee with whom he had a prior relationship. We also found that he directed a change to the minimum qualification language in a job solicitation to aid the same employee’s selection for Federal employment. We found no evidence to support the allegations against the other two officials involving hiring, noncompetitive supervisory reassignments, nepotism, or favoritism.We found that a BSEE official violated Federal regulations when he pursued a procurement action to hire an employee with whom he had a prior relationship.

We audited the Housing Authority of the City of North Chicago’s Housing Choice Voucher Program based on our analysis of risk factors related to the public housing agencies in Region 5’s jurisdiction and the activities included in our 2018 annual audit plan. Our audit objective was to determine whether the Authority appropriately managed its program in accordance with the U.S. Department of Housing and Urban Development’s (HUD) and its own requirements. The Authority did not adequately enforce HUD’s housing quality standards and its own requirements. Specifically, it failed to ensure that 78 program units, including 50 that materially failed, complied with HUD’s housing quality standards and its program administrative plan. As a result, more than $153,000 in program funds was spent on units that were not decent, safe, and sanitary. Based on our statistical sample, we estimate that over the next year, the Authority will pay more than $1.2 million in housing assistance for units with material housing quality standards violations. The Authority did not always comply with HUD’s and its own requirements for its program household files. It did not obtain and maintain required eligibility documentation and correctly calculate housing assistance and utility allowances. As a result, it lacked support for nearly $94,000, overpaid nearly $80, and underpaid nearly $2,200 in housing assistance. We recommend that the Director of HUD’s Chicago Office of Public Housing require the Authority to (1) certify that the applicable housing quality standards violations have been corrected for the 78 units cited, (2) reimburse its program from non-Federal funds for the 50 units that materially failed to meet HUD’s and its own requirements and for the household files with inappropriate calculations of housing assistance, (3) support or reimburse its program for the household files with missing documentation, (4) reimburse its program households from program funds for the underpayment of housing assistance, and (5) implement adequate procedures and controls to address the findings cited in this audit report.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Robley Rex VA Medical Center. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-risk Processes: Central Line-associated Bloodstream Infections. The Director and Associate Director positions were covered with interim appointees until the positions were permanently filled in August 2018 and January 2018, respectively. The leaders were generally engaged with employees and patients as evidenced by high satisfaction scores. Organizational leadership supported patient safety and quality care. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors; however, opportunity exists to improve care and positively affect Quality of Care and Efficiency metrics likely contributing to the Facility’s “3-Star” rating. The OIG noted findings in five of the eight clinical areas reviewed and issued nine recommendations attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analysis action feedback to reporting employees or departments (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) Environment of Care • Facility and CBOC cleanliness and maintenance • Inpatient mental health safety • Emergency Operations Plan and annual review of inventory and assets (4) Medication Management: Controlled Substances Inspection Program • Controlled Substances Coordinator’s monthly summary of findings • Annual physical security survey (5) Women’s Health: Mammography Results and Follow-up • Mammogram results electronically linked to radiology order