Federal Reports

The VA Office of Inspector General (OIG) conducted an inspection at the VA Northeast Ohio Healthcare System’s (the facility) Domiciliary Residential Rehabilitation Treatment Program to evaluate allegations of deficiencies in the care of a patient who died after an Emergency Department visit, as well as safety, security, and staffing at the domiciliary. In response to a congressional request, the OIG also evaluated whether Volunteers of America (VOA) met contractual agreement requirements for providing nonclinical staffing as well as food and cleaning services to the domiciliary program. The OIG did not substantiate that Emergency Department staff failed to properly assess the patient. There was not a conclusive determination that a cardiac event contributed to the patient’s death. However, the OIG found that no provider ordered an electrocardiogram prior to methadone initiation as recommended in VHA guidance. Facility leaders submitted an issue brief and conducted a review as required. The OIG determined that given the failure to obtain an electrocardiogram, facility leaders should also consider an institutional disclosure to the patient’s family. The OIG substantiated that VOA staff improperly completed health and safety round sheets. Other monitoring checks appeared to be completed as required. VOA managers stated that documentation was reviewed but accuracy was not verified. The physical security of the domiciliary building and grounds was in compliance with Veterans Health Administration requirements. The OIG determined that domiciliary nurse staffing was not unsafe because there was a minimum of two nurses on every shift along with VOA resident monitors. The domiciliary met or exceeded minimum core staffing requirements for other clinical staff. VOA substantially met its contractual obligations. The OIG made two recommendations to the VA Office of Asset Enterprise Management Director related to contract modifications, and three recommendations to the Facility Director related to electrocardiograms, institutional disclosure, and safety rounds.

Due to the current public health emergency and increased cyber-activity, we are only posting the title of our cybersecurity audits.

During a recent OIG investigation, we found that the National Indian Gaming Commission (NIGC) has an internal policy that permits authorized senior staff to obtain access to employee emails to ensure “efficient and proper operation of the workplace,” or to search for “suspected misconduct.” We found, however, that the NIGC has no systems, processes, or procedures in place to approve, track, or account for internal email queries of employees’ emails.While we found no U.S. Department of the Interior policy that prohibited such queries, we are concerned about the negative effect this practice could have on employees making protected disclosures. The U.S. Office of Special Counsel (OSC) issued a memorandum to all executive departments and agencies in February 2018 urging that policies and practices for monitoring employee communications “do not interfere with or chill employees from lawfully disclosing wrongdoing.”To avoid a chilling effect on NIGC employees seeking to engage in protected whistleblowing activity and to ensure adequate oversight of its access to individual Government email accounts, we made one recommendation that the NIGC establish formal policies and procedures consistent with the OSC’s guidance that also provide a way for the NIGC to track and retain all requests and productions.We issued this management advisory to the NIGC Chairman.

The Office of Inspector General is tasked with ensuring efficiency, accountability, and integrity in the U.S. Postal Service. We also have the distinct mission of helping to maintain confidence in the mail and postal system, as well as to improve the Postal Service's bottom line. We use audits and investigations to help protect the integrity of the Postal Service. Our Semiannual Report to Congress presents a snapshot of the work we did to fulfill our mission for the six-month period ending March 31, 2020. Our dynamic report format provides readers with easy access to facts and information, as well as succinct summaries of the work by area. Links are provided to the full reports featured in this report, as well as to the appendices.

To see our report, please click on the link below