Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Eastern Kansas Health Care System, which includes the Colmery-O’Neil VA Medical Center (Topeka), Dwight D. Eisenhower VA Medical Center (Leavenworth), and multiple outpatient clinics in Kansas and Missouri. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued three recommendations for improvement in the Environment of Care area of review:• Walls in good repair• Panic and over-the-door alarm testing in the inpatient mental health unit

This semiannual report summarizes the GPO OIG's activities and accomplishments from October 1, 2023, through March 31, 2024.

The Office of Inspector General (OIG) is issuing this management advisory to present the results of our review of the U.S. Small Business Administration’s (SBA) processing of Coronavirus Disease 2019 (COVID-19) Economic Injury Disaster Loan (EIDL) funds that were returned to the agency by borrowers, banks, or other sources.We found significant delays in the decision process related to returned COVID-19 EIDL funds. The majority of these COVID-19 EIDLs were eventually made available to small business owners, including the original borrowers. However, SBA canceled $3.1 billion of these loans, part of the returned COVID-19 EIDL funds, over several months.SBA also canceled $8.1 billion of undisbursed COVID-19 EIDLs. The agency had not disbursed these loans because of inaccurate applicant information or other reasons, including fraud indicators that had not yet been resolved. The returned and undisbursed COVID-19 EIDLS, totaling $11.2 billion, were canceled after the program closed, so the funds could not be made available to other eligible COVID-19 EIDL borrowers.On June 3, 2023, the Fiscal Responsibility Act of 2023 was enacted, which rescinded unobligated COVID-19 EIDL subsidy balances.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Nebraska-Western Iowa Health Care System, which includes the Grand Island and Omaha VA Medical Centers and multiple outpatient clinics in Nebraska, as well as one outpatient clinic in Iowa. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued two recommendations for improvement in two areas:1. Leadership and organizational risks• Institutional disclosures for sentinel events2. Medical staff privileging• Focused Professional Practice Evaluation results

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Illiana Health Care System, which includes the Danville VA Medical Center and multiple outpatient clinics in Illinois. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued two recommendations for improvement in two areas:1. Medical staff privileging• Service-specific criteria in professional practice evaluations2. Mental health• Comprehensive Suicide Risk Evaluation completion

The Making Advances in Mammography and Medical Options for Veterans Act of 2022 requires the VA Office of Inspector General (OIG) to report on mammography services and breast cancer care provided to veterans. In accordance with this requirement, the OIG conducted an evaluation of mammography services delivered through the outpatient settings of randomly selected VA medical facilities and community providers. The OIG also assessed the performance of VA’s Women’s Oncology System of Excellence and patients’ accessibility to a comprehensive care team, for those diagnosed with breast cancer, as required by the legislation.Because veterans receive mammography services and breast cancer care through VA and community providers, the OIG deployed teams from both its Comprehensive Healthcare Inspection Program (CHIP) and Care in the Community (CITC) program to gather data for this inspection.The OIG issued three recommendations for improvement to the Under Secretary for Health, VISN directors, facility leaders, and National Oncology Program staff to ensure:1. Facility leaders and staff are aware of the services offered to veterans diagnosed with breast cancer through the Women’s Oncology System of Excellence.2. The Under Secretary for Health and National Oncology Program staff offer a range of services for patients diagnosed with breast cancer, including rehabilitative services, through the Women’s Oncology System of Excellence.3. Staff enter data into the local cancer registry database in a timely manner.