Federal Reports

We conducted a limited scope audit of the American Architectural Foundation (AAF) for the period of May 1, 2014 through April 30, 2017. Limited scope audits involve a review of financial and non-financial information of grant recipients to ensure validity and accuracy of reported information, and compliance with federal requirements.Our limited scope audit concluded that the AAF generally did not comply with the financial management system and recordkeeping requirements established by the OMB and NEA. While performance requirements were generally satisfied, we identified multiple financial management areas requiring improvement to ensure that the AAF complies with OMB and NEA award requirements as follows:• The AAF included unallowable alcohol costs on all of the awards’ Federal FinancialReports (FFRs).• The AAF generally did not administer NEA awards in compliance with NEA and federalregulations, specifically regarding in-kind contribution costs, general and administrativecosts, internal controls, submitting final reports, or procuring goods and services.• The AAF included unsupported costs on all of the awards’ FFR.• The AAF included costs incurred outside the award period on the FFR for DCA 2016-01.3• The AAF did not provide accurate, current, and complete disclosure of the financialresults of federal awards.• The AAF did not comply with federal suspension and debarment requirements regardingcontractors and Institute speakers.• The AAF did not comply with NEA requirements to complete and maintain on file aSection 504 Self-Evaluation.

OIG's objective was to assess the cost, schedule, and technical performance of selected components of the Joint Polar Satellite System (JPSS) program. Specifically, the objective was to assess the JPSS ground project’s efforts to complete the Block 2.0 upgrade of the ground system. OIG also set out to determine whether the project properly supported award fee decisions and effectively managed ground system contractor performance.

The U.S. Postal Service offers a postage rate discount to mailers for presorting, pre-barcoding, handling, or transporting of mail. These workshare discounts incentivize mailers to perform specific activities that the Postal Service would otherwise have to perform. They allow the Postal Service to increase operational efficiencies, avoid some mailing costs, stimulate mail volume growth, and improve service. Our objective was to assess the accuracy and reliability of the Marketing Mail letters cost-avoidance model used to develop mail processing workshare discounts.

At the request of Senators Tammy Baldwin and Ron Johnson, the VA Office of Inspector General (OIG) conducted a healthcare inspection regarding the care and management of a patient who committed suicide less than 48 hours after discharge from William S. Middleton Memorial Veterans Hospital (Facility), Madison, Wisconsin. A second patient was also identified and reviewed. The OIG found that Facility managers correctly classified the patient’s death as a sentinel event and completed Veterans Health Administration and Joint Commission reporting requirements; however, the Facility’s root cause analysis process was deficient. A 72-hour hold was not required for the patient although it was considered by the provider. The OIG identified ethical concerns regarding the patient’s enrollment in a research study; a failure by staff to inform a community monitoring agency of the patient’s court settlement agreement violations, deficiencies in discharge planning; and inadequate post discharge follow-up. The OIG also identified deficiencies in psychiatric clinical pharmacists’ outpatient Mental Health (MH) care in the 15 months prior to the patient’s death and similar MH care deficiencies by a psychiatric clinical pharmacist in the care of another patient that died by suicide 13 months prior to the first patient’s death. The OIG made 11 recommendations related to institutional disclosures for both patients, an ethics review of the first patient’s participation in a research study, an expanded evaluation of the first patient’s death, court settlement agreements, revision of the MH unit policy, prescribing practices including adherence to black box warnings, the use of collaborative agreements and assignment of prescribers for patients with complex MH needs, and strengthening psychiatric clinical pharmacists’ supervision processes.