Federal Reports

The OIG investigated approximately $1,600 in fraudulent charges that were made on several Government charge cards issued to a U.S. Geological Survey employee.We found no evidence that the employee made the fraudulent charges and we discovered that a friend of the employee may have been responsible. As a result, we closed our investigation and referred this matter to the local police department.

U.S. Citizenship and Immigration Services (USCIS) adjudicates applications for immigration benefits, including applications for permanent resident cards, also known as green cards. In response to congressional concerns, we examined green card application processing times, as well as why processing times vary among USCIS field offices. USCIS regularly posts information on its website about the time it takes field offices to adjudicate green card applications (processing time). Yet, the information is unclear and not helpful to USCIS’ customers because it does not reflect the actual amount of time it takes field offices, on average, to complete green card applications

Please click the link below to access a press release describing this and other related documents.

Please click the link below to access a press release describing this and other related documents.

Please click the link below to access a press release describing this and other related documents.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Clement J. Zablocki VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home (CNH) Oversight. The OIG provided crime awareness briefings to 93 employees. The facility has generally stable executive leadership and active engagement with employees and patients; however, the senior leadership team has opportunities to improve patient safety, quality care, and perceptions about facility leadership. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results identified multiple organizational risk factors that may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented. The senior leadership team should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current 3-star SAIL rating. The OIG noted findings in five of the six areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Deputy Director. The identified areas with deficiencies are: (1) QSV • Review of credentialing and privileging data (2) Coordination of Care: Inter-Facility Transfers • Transfer data collection and reporting • Transfer documentation • Resident supervision • Communication with the accepting facility (3) EOC • EOC rounds frequency and attendance • Training for locked mental health unit employees (4) High-Risk Processes: Moderate Sedation • Training for staff who perform moderate sedation (5) Long-Term Care: CNH Oversight • Clinical visits for patients residing in CNHs