Federal Reports

For our final audit report conducted to review the NOAA Office of Marine and Aviation Operations (OMAO) ship fleet, our objective was to determine whether NOAA OMAO coordinates ship maintenance and repairs of its fleet using the Shipboard Automated Maintenance Management System (SAMMS).

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the South Texas Veterans Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 105 employees.The facility had stable executive leadership with the exception of the vacancy for the Associate Director; however, it appears that the vacancy has not impacted the provision of quality care. Facility leaders were actively engaged with employees and patients and were working to improve satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the facility’s current 3-star rating. OIG noted findings in two of the areas of clinical operations reviewed and issued three recommendations that are attributable to the Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are:(1) Environment of Care• Safety and infection prevention on the cardiac intensive care unit at the parent facility• Locked mental health unit employee and Interdisciplinary Safety Inspection Team member training(2) Long-Term Care: Community Nursing Home Oversight• Clinical visits for patients residing in community nursing homes

This briefing paper highlights challenges the Department of Housing and Urban Development (HUD) faces in managing and improving its Information Technology (IT) program. This document analyzed past HUD OIG and GAO IT related reports and recommendations to highlight key management challenges in HUD’s IT program. We are highlighting these challenges so HUD leadership is aware of and can be better prepared to address them.The OIG has determined that the contents of this report would not be appropriate for public disclosure and has therefore limited its distribution to selected officials. Please contact the Office of Evaluation at evaluations@hudoig.gov to request a copy of this report.

OIG investigated allegations that a National Park Service (NPS) senior official in the Northeast Region used his position for personal gain when he requested unnecessary design and construction improvements to a park housing unit he expected to rent as his personal residence. We also investigated allegations that the senior official made improper position changes by preselecting a staff member who did not meet qualifications and that he improperly served on park partner organization boards.We found that the NPS senior official created the appearance of using his public office for private gain when he asked his subordinate employee to include specific design and construction changes in the renovation proposal for a historic townhouse, which was the park housing unit in which he planned to reside. The changes were included in the final design plans and added approximately $32,000 to the cost of the project, but at the time of our report, the senior official had decided not to move into the unit and NPS had delayed the renovations.We also found that some employees and contractors did not agree with the proposed changes, and only one person raised these concerns before the project was awarded. Additionally, we found that members of the Regional Development Advisory Board, whose role was to review and approve the proposed renovation plans, were not aware that the senior official had intended on moving into the unit.We did not substantiate that the NPS senior official made improper position changes by preselecting staff members, and we found that while the senior official did serve as an NPS liaison for two park partners, his participation did not violate NPS or ethics regulations.

OIG investigated an allegation that an employee with the Office of Surface Mining Reclamation and Enforcement (OSMRE) attempted to send a spreadsheet containing personally identifiable information (PII) for over 180 DOI employees to his personal email account.We found that the employee made repeated attempts to send the spreadsheet from his Government email account to his personal account, in violation of the DOI’s employee policy on network use. We confirmed, however, that the DOI’s IT security systems blocked the emails and prevented the PII from being transmitted to his personal account or computer. The employee’s supervisor confiscated the employee’s work computer the day he learned of the attempts to email the spreadsheet and placed the employee on administrative leave. When we first interviewed the employee, he denied trying to send the spreadsheet containing PII to his personal email, but during a later interview he admitted that he had. He also told us that he tried to send the spreadsheet because he liked to save and organize files on his home computer and not for illegal or inappropriate purposes. In addition, we found that he had attempted to send the PII knowing that his home computer had a software program installed on it that allowed for outside access. Finally, we learned that the employee had been disciplined in the past for lack of candor.We referred this case to the U.S. Attorney’s Office, Washington, DC, which declined to prosecute.

We evaluated U.S. and Coalition progress towards accomplishing the Train, Advise, Assist Command-Air (TAAC Air) mission to develop the Afghan Air Force into a professional, capable, and sustainable force.

New York did not always determine Medicaid eligibility for newly eligible beneficiaries in accordance with Federal and State requirements. In our sample of 130 beneficiaries, New York correctly determined eligibility for 90 beneficiaries. However, it did not determine eligibility for 37 beneficiaries in accordance with Federal and State requirements and did not provide supporting documentation to verify beneficiaries were newly eligible for the remaining 4 potentially ineligible beneficiaries. The total exceeds 130 because 1 beneficiary was found to be ineligible for one determination period and found to be potentially ineligible for another determination period. On the basis of our sample results, we estimated that New York made Federal Medicaid payments of $26.2 million on behalf of 47,271 ineligible beneficiaries.