Federal Reports

For our audit of the U. S. Patent and Trademark Office’s (USPTO’s) Software Development and Integration–Next Generation (SDI-NG) contracts, our audit objective was to determine whether USPTO provided adequate oversight of SDI-NG contracts. To address this objective, we specifically assessed whether USPTO provided adequate oversight of (1) the acquisition planning process and (2) vendor performance.Overall, we found that USPTO did not provide adequate oversight of the SDI-NG Bridge. Specifically, we found the following: I. USPTO did not timely plan and compete a follow-on SDI-NG contract and II. USPTO did not adequately document and use vendor performance information.

The COVID-19 pandemic has affected how the Veterans Benefits Administration (VBA) provides disability benefits to veterans. On April 3, 2020, VBA discontinued all in-person disability exams that help determine the severity of medical conditions and the amount of benefits paid. The OIG conducted this review to assess how VBA scheduled and conducted exams during the pandemic to limit veterans’ exposure, minimize processing delays, and ensure claims were not prematurely denied due to missed or canceled in-person exams. The OIG also evaluated VBA’s strategy for addressing the inventory of delayed disability exams.VBA responded decisively to the pandemic by shifting exams to contractors, modifying procedures, and notifying veterans of their options. These included telehealth exams, reviews of acceptable clinical evidence, or the opportunity to wait for an in-person exam with the assurance that no final action would be taken until in-person exams could be completed. However, VBA and the OIG identified claims prematurely or improperly denied based on canceled exams, contrary to issued guidance.In response, VBA clarified guidance and established additional controls such as establishing a new program office focused on exam management operations and oversight. The OIG found that while the exam inventory has increased (about 1.5 million exams needed as of July 31), the percentage of errors decreased with clearer guidance. Still, VBA must further develop, implement, and test its strategy for reducing the growing inventory of pending exams while handling incoming exam requests. The plan must incorporate lessons from COVID-19 responses to ensure continuity of exam processing and to prepare for future national emergencies.VBA concurred with the OIG’s two recommendations to further develop, implement, and test the strategy to reduce the exam inventory and to implement a plan increasing the use of telehealth exams and ensuring contractors follow VBA guidance. (Click here for related infographic.)

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review an allegation that a patient died in the Emergency Department waiting room at the VA Loma Linda Healthcare System.The OIG did not substantiate the allegation. The facility policy did not require the first look nurse, who assigned an Emergency Severity Index level 3 (1–most urgent to 5–least urgent) to the patient, to take vital signs. Two hours later, the triage nurse obtained the unarousable patient’s first set of vital signs and documented a rapid heart rate. Following transport to an Emergency Department room, a physician noted no heart sounds and no pulse. The family declined life sustaining interventions and the patient died shortly thereafter. The OIG determined that Emergency Department staff followed triage protocols.Mental health clinic nursing staff at the Ambulatory Care Center failed to assess and document the patient’s condition during maintenance care for a urine catheter bag. Although the omission may not have affected the patient’s care, complete and accurate documentation is essential to coordinating and providing comprehensive care.The OIG found that primary care nursing staff did not provide a hand-off communication to the Emergency Department but was unable to determine if this affected the patient’s outcome.The facility addressed 9 of 11 systems issues identified by its fact-finding review completed after the patient’s death and planned to address the remaining issues in fall 2020. The facility revised the first look nurse policy to require obtaining and documenting a patient’s vital signs within 10 minutes of arrival but had only 65 percent compliance with the updated policy. Three recommendations were made to the Facility Director related to providing documentation training for mental health clinic staff, reviewing the hand-off communication policy, and ensuring compliance with the revised first look nurse policy.

In April 2018, the GPO Office of the Inspector General (OIG), Investigations Division, received a referral from the Federal Bureau of Investigation (FBI) alleging fraudulent activities committed by DLUX Printing & Publishing, Inc. (DLUX) – a business located in Pensacola, FL. The complainant, who had intimate knowledge of DLUX’s day-to-day operations, reported that Gerald Mandel (Mandel), the owner of DLUX, directed employees to produce and distribute a fraction of the contracted materials, while still invoicing the GPO for the full amount.g