Federal Reports

From March to July 2022, The AmeriCorps Office of Inspector General (OIG) conducted a modified peer review of the AbilityOne OIG’s Office of Audit (OA). The team from AmeriCorps OIG reviewed (1) the OA’s established audit policies and procedures in effect for the year ended September 30, 2021, and (2) the OA’s monitoring of Government Audit Standards (GAS) engagements performed by Independent Public Accountants (IPAs).

An Amtrak conductor based in Sanford, Florida, was suspended from his position without pay, in lieu of termination, on July 15, 2022, following his administrative hearing. The employee was held out of service without pay for a total of 68 days from May 26, 2022, through August 1, 2022. Our investigation found that the employee violated company policies by attempting to sell high-security switch keys and other assorted railroad keys on Facebook Marketplace, including keys used by Amtrak.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 5: VA Capitol Health Care Network in Linthicum, Maryland, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The executive leaders, who had worked together since August 2020, had spent much of their time and efforts on improving care and leadership at the Louis A. Johnson VA Medical Center following an OIG criminal investigation of a VA nursing assistant who was convicted and sentenced for the murder of seven veterans. Leaders reported taking actions such as ensuring staff completed Morbidity and Mortality reviews, evaluating quality of care through an Administrative Investigation Board, and monitoring hiring and background check processes.Selected survey scores related to employee satisfaction with VISN leaders generally exceeded VHA averages; however, the Deputy Network Director’s servant leadership score was lower than the VHA average. VISN patient experience survey scores were similar to VHA averages, except for inpatient care satisfaction at selected VISN 5 facilities. The OIG identified potential risk factors including mental health wait times at selected facilities over 20 days, higher rates of clinical vacancies, and challenges with facility hiring support and retention of human resources staff. The Network Director, Chief Medical Officer, and Quality Management Officer/Chief Nursing Officer had opportunities to improve oversight of facilities’ quality, safety, and value; care coordination; and high-risk processes.The OIG issued one recommendation for improvement:(1) Medical Staff Credentialing• Physician credentials review process