Federal Reports

We found that the post’s financial and administrative operations required significant improvement to comply with agency policies and applicable Federal laws and regulations. Our report contains 25 recommendations directed to both the post and headquarters. At the post, our recommendations included strengthening controls over managing imprest funds, bills of collections, security certifications, and Volunteer payments; ensuring collection of all necessary receipts to claim value added tax refunds; and ensuring proper management oversight of grants, vouchers, and credit cards. Management concurred with all 25 recommendations.

An Amtrak Extra Board Lead Service Attendant in Chicago, Illinois, was terminated from employment on August 23, 2018, following an administrative hearing for violating company policy by stealing company funds and financial paperwork, wrongfully engaging in outside employment while on medical leave, and failing to cooperate with the OIG during the investigation.Our investigation revealed that the employee stole approximately $2,418.25 in cash and/or the cash equivalent value of unaccounted for/missing inventory. Additionally, we found that the employee worked at a local university while on medical leave from the company. Criminal judicial proceedings related to this case are pending in the Circuit Court of Cook County, Illinois.Amtrak OIG conducted this joint investigation with the Amtrak Police Department.Date Posted:

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations that the Samuel S. Stratton VA Medical Center’s peer review processes did not follow Veterans Health Administration (VHA) policy; the surgeon performed intraoperative radiofrequency ablation (IORFA) surgery for hepatocellular carcinoma and “completely missed” tumors in patients; a surgeon told a patient there was a recurrence of a tumor although it was “completely missed” during IORFA surgery; the surgeon performed cancer surgery on patients who did not have cancer; and adverse events occurred during and after the surgeon’s other cancer surgeries. The OIG substantiated the facility’s peer review process did not follow VHA policy, and the facility did not meet credentialing and privileging requirements. The OIG substantiated the surgeon completely or partially missed tumors when performing IORFA in three patients and told patients they had residual tumors when tumors were not initially ablated. The OIG determined that facility leaders did not provide disclosures for the patients reviewed. The OIG did not substantiate the surgeon performed surgery on patients who did not have cancer or that adverse events occurred during cancer surgeries. The OIG made nine recommendations related to reviewing quality oversight and quality data for professional practice evaluations; improving peer review programs; including accurate performance data for Surgery Service’s professional practice evaluations; developing and implementing processes to document, report, and track discussed patient cases; implementing processes to track, monitor, and report IORFA outcomes; consulting with Office of General Counsel on patients with missed tumors to institutionally disclose if appropriate; assessing the Surgeon’s IORFA outcomes; performing external reviews of IORFA processes; and evaluating actions for relevant staff.

The VA Office of Inspector General (OIG) reviewed whether the Veterans Benefits Administration (VBA) accurately notified veterans of proposed reductions in their disability evaluations and assigned correct effective dates for reduced evaluations completed from February 1 through July 31, 2017. The OIG estimated that 2,200 of 5,900 cases (38 percent) were processed incorrectly by VBA staff, resulting in an average improper payment rate of $2,000 per veteran. The OIG estimated that over a five-year period, VBA staff would make improper payments to over 22,300 veterans totaling more than $27.5 million. In addition, based on the OIG’s projections and estimates, veterans potentially could have received improper payments totaling approximately $10.4 million, of which approximately $7.8 million would be ongoing monthly improper payments. Errors included the assignment of incorrect effective dates for reduced disability evaluations; staff not sending amended notifications when the reasons for the proposed reductions changed; and staff providing inaccurate, or failing to send, initial notifications to veterans that their benefits may be reduced. These errors occurred because VBA staff did not always immediately process final actions for reduced evaluations, VBA’s electronic claims processing system defaulted to incorrect effective dates, compensation service staff did not require refresher training on how to process reduced evaluations, Veteran Service Representatives were more focused on meeting workload production standards and not ensuring correct effective dates, and VBA procedures did not specify when staff need to send notifications in the event a veteran’s disability evaluation is reduced. The OIG recommended VBA implement a plan to ensure the timely processing of these cases; modify the Veterans Benefits Management System to apply correct effective dates; provide refresher training; update guidance on amended proposal letters; and conduct reviews for veterans who had evaluations reduced, take corrective action, and provide certification of completion to the OIG.