Federal Reports

During our August 2017 site visit to the FLETC Artesia Training Center, we identified a potential safety issue at a warehouse, Building 13. The Border Patrol Academy had been using the warehouse to train new hires on search and conveyance. In 2009, a vehicle from an adjacent driving course struck the warehouse. FLETC officials could not provide documentation to support that an engineering evaluation was conducted to determine whether the accident affected the integrity of the warehouse structure. Border Patrol Academy officials also expressed safety concerns about using the warehouse to train new hires.

During our August 2017 site visit to the FLETC Artesia Training Center, we identified a potential safety issue at a warehouse, Building 13. The Border Patrol Academy had been using the warehouse to train new hires on search and conveyance. In 2009, a vehicle from an adjacent driving course struck the warehouse. FLETC officials could not provide documentation to support that an engineering evaluation was conducted to determine whether the accident affected the integrity of the warehouse structure. Border Patrol Academy officials also expressed safety concerns about using the warehouse to train new hires.

In accordance with FY 2017 IG FISMA Reporting Metrics, the objective of the evaluationwas to determine the effectiveness of the information security program and practices of theCommission. The scope of this evaluation focused on the Commission’s General SupportSystem (GSS) and related information security policies, procedures, standards, andguidelines.

We determined whether the Joint Attack Munition Systems (JAMS) project office adequately assessed the affordability of the Joint Air-to-Ground Missile (JAGM) increment one.

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the Bath VA Medical Center (facility). This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 29 employees.The facility has generally stable executive leadership and active engagement with employees and patients as evidenced by high 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 results did not identify any substantial organizational risk factors. OIG noted findings in five of the six areas of clinical operations reviewed and issued 11 recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Credentialing and privileging data reviews• Utilization management documentation(2) Medication Management: Anticoagulation Therapy• Provision of medication education to patients(3) Environment of Care• Environment of care rounds frequency and attendance• Maintenance of required number of filled oxygen tanks and an adequate supply of personal protective equipment• Storage of clean and sterile supplies(4) Mental Health Residential Rehabilitation Treatment Program• Monthly self-inspections, weekly contraband inspections, every 2-hour rounds of public spaces, and daily resident room inspections• Security at entrance doors

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 VA Eastern Kansas 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 118 employees.The facility had generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the facility through active stakeholder engagement). OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and SAIL results did not identify any substantial organizational risk factors.OIG noted findings in four of the six areas of clinical operations reviewed and issued five recommendations that are attributable to the Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value• Review of Ongoing Professional Practice Evaluation data• Documentation of decisions by Physician Utilization Management Advisors(2) Medication Management: Anticoagulation Therapy• Education for patients with newly prescribed anticoagulant medications(3) Environment of Care• Locked Mental Health Unit Interdisciplinary Safety Inspection Team training(4) Long-Term Care: Community Nursing Home Oversight• Cyclical clinical visits

The U.S. Department of health and Human Services (HHS) oversees States' administration of various Federal programs, including Medicaid. State agencies are required to establish appropriate computer system security requirements and conduct biennial reviews of computer system security used in the administration of State plans for Medicaid and other Federal entitlement benefits. This review is one of a number of HHS OIG reviews of States' computer systems used to administer HHS-funded programs.

We conducted a series of OIG audits at four HHS Operating Divisions (OPDIVs) using network and web application penetration testing to determine how well HHS systems were protected when subject to cyberattacks.

Statement of the Honorable Eric M. Thorson, Inspector General, Department of the Treasury, Office of Inspector General, provided to the House Financial Services Committee Subcommittee on Oversight and Investigations for the hearing on "Examining the Office of Financial Research", December 7, 2017 10am. (Written Testimony)