Federal Reports

The VA Office of Inspector General (OIG) assessed all identified 2015 initial Traumatic Brain Injury (TBI) Compensation and Pension (C&P) Examinations to determine if the examiners met certain VA stipulations. The OIG conducted the review in response to a legislative mandate and it was expanded at the request of Representatives Tim Walz (MN) and Mike Coffman (CO) to inform the House Committee on Veterans’ Affairs about whether qualified care providers are conducting TBI C&P examinations. Also, as directed by Congress, the OIG reviewed a veteran’s case and related complaint to the Montana Board of Psychologists to help inform the review. The OIG found that among the 13,301 contractor examinations and 17,778 examinations performed by Veterans Health Administration staff, VA practice was generally consistent with stipulations related to the specialty and training of providers. The OIG determined, however, that the training curriculum requirements for conducting examinations lacked rigor. In addition, the documentation of TBI C&P examination findings was insufficient to identify what the basis was for assessment of findings of cognitive impairment or residuals (the symptoms and affected bodily functions) of TBI. The OIG recommended that the VA’s Executive in Charge, performing the duties of the Under Secretary for Health and the Acting Under Secretary for Benefits convene experts to develop a plan that: 1) Ensures personnel performing TBI C&P examinations have comprehensive training on the evaluation of TBI, including the assessment and evaluation of cognitive disorders; 2) Develops requirements for documenting the TBI C&P examination process, including the basis for determinations; and 3) Considers whether disability ratings should be provided to veterans with claims arising from cognitive issues based on their clinical signs and symptoms, rather than primarily on the diagnoses or causes of their cognitive deficits.

In light of the heightened public and congressional interest in the misuse of government-owned, government-leased, and chartered aircraft, the Department of Homeland Security (DHS) Office of Inspector General (OIG) conducted a special review of the use of government aircraft by the heads of the Department and several of DHS’s operational components. DHS OIG’s review also included a review of other-than-coach-class travel by this same group of senior officials. We determined that each instance of the use of government aircraft by DHS’s senior leaders during the time period of our review generally complied with relevant laws, rules, regulations, policies, and guidance.With respect to DHS senior leaders’ other-than-coach-class (OTCC) commercial air travel over the same time period, we determined that such travel generally qualified as allowable premium travel. We could not definitively determine, however, whether one trip taken by a former Deputy Secretary met all of the Department’s criteria for allowable OTCC travel. We also identified two specific instances of non-compliance with the Department’s internal request and approval processes for such travel; however, the related travel was properly justified, and the process deviations were quickly identified and corrected by the Department.

U.S. Senator Claire McCaskill asked us to review ICE’s modification of its intergovernmental service agreement (IGSA) with the City of Eloy in Arizona to procure family detention space in Dilley, Texas. We also reviewed other selected IGSAs to determine whether they complied with applicable laws and regulations. ICE is responsible for the detention of removable aliens. ICE commonly uses a type of agreement called an IGSA to reserve space at detention facilities owned or operated by state or local governments.In September 2014, ICE improperly modified an existing IGSA with the City of Eloy (Eloy) in Arizona to establish the 2,400-bed South Texas Family Residential Center in Dilley, Texas, more than 900 miles away. Although ICE could have contracted directly with the private company that operates the South Texas Family Residential Center, CCA, it instead created an unnecessary “middleman” by modifying its existing IGSA with Eloy. Eloy’s sole function under the modification is to act as the middleman between ICE and CCA; Eloy collects about $438,000 in annual fees for this service.

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations about a failure in notifying a patient of test results at the VA Connecticut Healthcare System, West Haven Campus. The complainant alleged (a) a urologist failed to advise a patient of prostate-specific antigen (PSA) results, and the lack of notification allowed prostate cancer to spread to his lymph nodes and seminal vessels; (b) a provider failed to inform the patient of his high PSA reading greater than (>) 9.0 collected in mid–2015; and (c) 6 months elapsed before he was informed that his PSA was >11.0, and he had prostate cancer. The OIG did not substantiate the provider failed to notify the patient about an elevated PSA test result. The patient had a PSA done on Day 1. According to the patient in an interview, the provider notified him the PSA test result was elevated during a clinic visit on Day 3. The provider documented that the patient should return to the facility the next week for further testing. The significance of the PSA test was not known on Day 3; additional testing was needed to determine the reason for the elevated level. The OIG did not find evidence of a scheduled return appointment or visit the next week for a repeat PSA. The next scheduled appointment was several months later, on Day 134, for a Mental Health Pharmacy visit. A prostate biopsy on Day 227 was positive for cancer. The patient subsequently underwent surgical and radiation therapy. Although the OIG found the patient was informed of his mid-2015 PSA results, the OIG did not find documentation of patient notification regarding the Day 3 abnormal urinalysis test result. The OIG recommended that the Facility Director ensure providers follow Veterans Health Administration policy related to patient notification of test results.

A former Amtrak Superintendent of Transportation at Chicago Union Station, Benjamin Sheets, was sentenced on February 27, 2018, in the Federal District Court of Northern Illinois after pleading guilty to making false statements to our agents in violation of 18 U.S.C. § 1001(a)(1).

At the request of the Tennessee Valley Authority's (TVA) Supply Chain, we examined the cost proposal submitted by a company for civil projects and coal combustion residual program management work at TVA's steam electric power plants. Our examination objective was to determine if the company's cost proposal was fairly stated for a planned <br> $50 million contract.In our opinion, the company's cost proposal was overstated. Specifically, we found the company's proposed costs for a Cumberland Fossil Plant project and proposed unit rates for a Bull Run Fossil Plant project included overstated (1) labor markup rates, (2) labor costs, (3) material costs, (4) equipment costs, (5) subcontract costs, and (6) other direct costs. In addition, the company's proposed contract rate attachment for employees who receive no benefits was not representative of the company's actual benefit structureWe estimated TVA could avoid about $5.2 million on the planned $50 million contract by negotiating appropriate reductions to (1) labor markup rates, labor costs, material costs, equipment costs, subcontract costs, and other direct costs in the Cumberland Fossil Plant proposal and (2) unit rates in the Bull Run Fossil Plant proposal. In addition, we suggest TVA require the company (1) eliminate the rate attachment for field temporary or local hires with no benefits and (2) submit a rate attachment for employees with limited benefits to more accurately reflect the company's benefit structure.(Summary Only)

In 2008, the Office of Inspector General (OIG) conducted an agreed upon procedures engagement of specialty pay and made nine recommendations. As of September 15, 2014. the Department had fully implemented the recommendations. We conducted this performance audit to assess the Department’s compliance with governing directives and effectiveness of controls for specialty pays. The objectives of the audit were to determine if the Department (1) properly accounted for Specialty Pay Programs and (2) complied with applicable directives related to the personnel compensation programs such as eligibility requirements. The scope included the Hazardous Duty Pay, Plainclothes Pay, and FTO Pay during Fiscal Year (FY) 2016 and FY 2017.

Our objective was to determine whether NOAA established and administered BPAs in accordance with laws, regulations, and agency guidance. We reviewed a total of 30 BPAs— 17 GSA Schedule BPAs and 13 NOAA-established BPAs. Overall, we found that NOAA did not properly establish or administer all 30 BPAs because they did not comply with at least one or more of the key FAR and NOAA requirements.