Federal Reports

This report is the result of an Office of Inspector General (OIG) inspection of the VA Medical Center in Washington, D.C., (DC VAMC) that began in March 2017 after receiving a confidential complaint. The OIG released an interim report on April 12, 2017, identifying risks to patients and VA assets. This final report provided findings in four areas: (1) risk of harm to patients, (2) hospital service deficiencies affecting patient care, (3) lack of financial controls, and 4) failures in leadership. The OIG found that critical deficiencies at the DC VAMC were pervasive and persistent—often spanning many years—but were not successfully remediated by leaders at multiple levels within VA. These deficiencies impacted core medical center functions that healthcare providers need to effectively provide quality care. The report details the DC VAMC’s failures in ensuring supplies and equipment reached patient care areas when needed, processing and sterilizing instruments, managing and securing assets, maintaining cleanliness, providing timely prosthetic devices, properly reporting and analyzing patient safety events, and receiving the staffing and leadership needed for sustainable change. The OIG did not find evidence of adverse clinical outcomes, a condition that is largely attributable to front-line care providers who were committed to providing the best possible care by borrowing supplies, improvising, or personally ensuring patients received what they needed. The OIG made 40 recommendations and VA concurred with each one. VA also provided detailed action plans on how the recommendations are going to be implemented and identified the progress they have already made. This report is meant to not only improve conditions at the DC VAMC, but also to serve as a roadmap for other VA medical facilities and to improve integrated reviews and oversight by Veterans Integrated Service Networks and VA central offices.

Department of Homeland Security (DHS) Under Secretary for Intelligence and Analysis (USIA) David J. Glawe used a personal email account to send an invitation to his ceremonial swearing-in event to staff members of the United States Senate Committee on Homeland Security and Governmental Affairs. Because the invitation came from a non-DHS email account and resembled a phishing email, Senator Claire McCaskill asked the DHS Office of Inspector General to review the circumstances surrounding the invitation.

We reviewed DHS’ information security program in accordance with the Federal Information Security Modernization Act of 2014 (FISMA). Our objective was to determine whether DHS’ information security program and practices were adequate and effective in protecting the information and information systems that supported DHS’ operations and assets in fiscal year 2017. The Department of Homeland Security could protect its information and systems more fully and effectively. DHS’ information security program fell one level below the targeted “Level 4” in three of five areas listed in this year’s FISMA reporting instructions.

The objective of this audit is to determine whether internal controls for issuing permit postage and fee refunds were in place and effective at the Palm Coast, FL, Branch.The U.S. Postal Service Office of Inspector General (OIG) Field Financial Risk Model identified that the Palm Coast Branch refund and void amounts for fiscal year 2017 Quarters 3 and 4 exceeded $105,000, an increase of 110 percent from the same period last year. Of the $105,000 in refunds and voids, $96,551, or 92 percent, were recorded as refunds of permit postage and fees. We audited 100 percent of the permit postage and fee refunds based on this refund category having the highest dollar value refund activity between April 1 and September 30, 2017.

This Newsletter provides a bimonthly summary of selected investigative accomplishments.

OIG investigated allegations that a former Bureau of Indian Affairs (BIA) contracting employee had a conflict of interest involving a government contractor. We also investigated allegations that the employee had an inappropriate relationship with a second government contractor.Our investigation confirmed the allegations. The employee signed an agreement with a contractor to assist the contractor in obtaining government contracts in exchange for the employee receiving help to develop business on an Indian reservation. The employee denied the conflict of interest, however, the contractor provided us with the contract, which bore the employee’s signature.We further determined that the employee attended social functions and accepted at least one meal from the second government contractor, a prohibited source. The employee also failed to disclose multiple outside employment interests and income as required by government regulation.The employee left the Department. Prosecution was declined by the U.S. Attorney for the District of New Mexico.

OIG investigated allegations that a Bureau of Indian Affairs (BIA) employee improperly used a BIA purchase card to purchase speakers, headphones, and electronic tablets.Prior to any significant involvement by our office, we learned that BIA had already investigated the matter and confirmed that two employees inappropriately purchased and gave to colleagues eight headphones and two wireless speakers, totaling $2,931.92. One of the employees also used his personal funds to improperly purchase five tablet computers at a discounted rate through a BIA contract. Both employees involved in the purchases left the Department.Our investigation also found two supervisors were responsible for approving the purchase card purchases. One supervisor received a letter of reprimand, and the other was removed from Federal service. The United States Attorney’s Office for the District of South Dakota declined prosecution of this matter.

The objective of our audit was to assess whether the U.S. Postal Service effectively managed its Limited Duty and Rehabilitation programs to ensure that injured employees in the Southern and Pacific areas who were deemed fit returned to work timely.The Postal Service’s Limited Duty and Rehabilitation programs help the agency meet its legal obligation to injured-on-duty employees, including the requirement to return them to work within their medically defined work restrictions. These programs accommodate employees who are temporarily unable to perform their regular job and assist employees with permanent disabilities.The Postal Service tracks employees who are deemed fit to return to work in a limited duty capacity via its No Work Available (NWA) list; however, there are no assignments available at this time. On May 17, 2017, there were 1,243 employees on the NWA list nationwide, 489 of whom were in the Southern and Pacific areas.