Federal Reports

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.

The Federal Information Security Modernization Act of 2014 requires Federal agencies to develop, implement, and manage agency-wide information security programs. Agencies are also required to provide acceptable levels of security for the information and systems that support their operations and assets.

The Federal Information Security Modernization Act of 2014 also mandates that the Office of Inspector General conduct an independent evaluation to determine whether the Department of Energy’s unclassified cybersecurity program adequately protected its data and information systems in accordance with Federal and Department requirements.

Our fiscal year 2024 Federal Information Security Modernization Act of 2014 evaluation determined that the Department, including the National Nuclear Security Administration, had taken actions to address some of the previously identified weaknesses related to its unclassified cybersecurity program. While actions were taken to close 19 of 63 (30 percent) recommendations from our prior year audits and evaluations, 44 prior year recommendations remained open. We also issued 79 new recommendations throughout the fiscal year related to various areas of cybersecurity programs.

The weaknesses identified occurred for a variety of reasons. For instance, findings at some Department sites had occurred due to vulnerability management processes that were not fully effective in identifying, addressing, and/or remediating vulnerabilities. We also found that several sites had not fully developed and/or maintained policies and procedures to help facilitate the design and implementation of security controls.

Without improvements to address the weaknesses identified in our report, the Department may be unable to adequately protect its information systems and data from compromise, loss, or modification.

When fully implemented, the 123 recommendations made during fiscal year 2024 should help to enhance the Department’s unclassified cybersecurity program. The Department should emphasize closing findings in a timely manner, especially those findings repeated from prior years. As cybersecurity remains an ongoing challenge, it is important that the Department take action to implement the latest Federal cybersecurity requirements and enhancements to assist in ensuring adequate protection of the Department’s data and information systems at risk to emerging threats and vulnerabilities.
 

We initiated this report to address allegations on failures of the Department of Energy to provide effective oversight of travel card use by a political appointee. This report also presents findings related to a limited number of other political appointees and Department senior executives (collectively, “Executives”).

Our review substantiated four of the five items noted in the allegation regarding misuse or abuse of the rules and regulations related to the political appointee. We did not substantiate the allegation related to use of split disbursements.

Additionally, our review found that weaknesses were not just limited to the individual identified in the allegation but extended to a small number of other Executives within the Department. We found that certain Executives misused their Government-issued travel cards by making personal purchases using the cards and maintaining delinquent travel card account balances. Upon notification of travel card issues by the Office of Travel Management, we found that Executive leadership did not always act on the derogatory information provided related to travel card misuse. Notably, the misuse and lack of leadership action was not limited to any one program but identified across many Department program elements.

This report provides areas of consideration for the Department, specifically focused on enhancing controls in this area, including ensuring that timely and appropriate actions are taken in response to reported travel card misuse and delinquencies.