Federal Reports

We are pleased to present the Top Management Challenges Report. In accordance with the Reports Consolidation Act of 2000, the Inspector General reports on the most serious management and performance challenges facing the U.S. AbilityOne Commission. We illustrate new challenges such as the challenge to effectively allocate scarce resources rather than lack of resources and we included continuous work on financial management as a challenge for this year. The Commission designates Central Nonprofit Agencies (CNAs) to facilitate employment of people who are blind of have significant disabilities. the dynamics of the CNAs in the program are changing and growing. Our reporting reflects on, and seeks to assist in, this challenging environment.In this year's Top Management and Performance Challenges Report we include the most pressing challenges: 1) allocation of roles, resources and responsibilities 2) implementation of 898 panel recommendations, 3) Anti-deficiency Act violations, 4) transparency, 5) erosion of statutory program authority, 6) implementation of cooperative agreements, 7) a lack of risk management, and 8) needed enhancements to program compliance.

An Amtrak locomotive technician based in Seattle, Washington, was terminated from employment on November 12, 2020, following his administrative hearing. Our investigation found that the former employee violated company policies by driving a company-owned vehicle without a valid driver’s license on at least two occasions. We also found that the former employee failed to report an arrest and subsequent conviction to the company for a driving under the influence violation as required by company policy.

In accordance with the Reports Consolidation Act of 2000, we are submitting what we have determined to be the most significant management and performance challenges facing the U.S. Department of the Interior (DOI), for inclusion in the DOI’s Agency Financial Report for fiscal year 2020.Given the broad effects of the COVID-19 pandemic on not only the DOI but the United States as a whole during this fiscal year, we have modified our approach for this year’s report to feature a detailed analysis of the DOI’s pandemic response. We are not suggesting that the challenges we identified in previous years have been resolved, but, under the circumstances, we believe that they should be viewed in light of the pandemic and its substantial effect on the DOI.We also identify an emerging issue—namely, the implementation of the Great American Outdoors Act—and the DOI’s progress in preparing for and addressing this challenge.This report is primarily based on Office of Inspector General (OIG) and U.S. Government Accountability Office (GAO) reviews (including the GAO’s High-Risk List), as well as our general knowledge of the DOI’s programs and operations.

Adam Micek, of Queens, New York, was sentenced in U.S. District Court, Eastern District of New York, on November 12, 2020, to a prison term of time served, probation for 36-months and was ordered to pay restitution of $132,787. Micek previously pleaded guilty to conspiracy to commit wire fraud for his involvement in an Amtrak eVoucher scheme. Our investigation found that Micek and his co-conspirators used stolen credit card information to make unauthorized purchases of Amtrak tickets and then cancelled or exchanged those tickets for eVouchers. Subsequently, they sold the fraudulently obtained eVouchers on the internet.

The Office of Inspector General issued a report discussing the Top Management and Performance Challenges facing NASA.

In 2018, senior DHS and U.S. Customs and Border Protection (CBP) leaders issued public statements urging undocumented aliens seeking asylum to enter the United States legally at ports of entry, while also directing ports of entry to focus on other priority missions and institute practices to limit the number of undocumented aliens processed at ports of entry. CBP Office of Field Operations (OFO) personnel at 24 Southwest Border ports of entry implemented a practice known as queue management, where an officer manned a “limit line” position at or near the U.S.-Mexico border to control the number of undocumented aliens entering the port. We identified that seven of these ports stopped processing virtually all undocumented aliens, including asylum seekers, by redirecting them to other ports located miles away. This redirection contravenes CBP’s longstanding practice to process all aliens at a “Class A” port of entry or reclassify the port of entry. Additionally, CBP officers at four ports returned undocumented aliens to Mexico despite a legal requirement to process asylum claims of aliens that are physically present in the United States. We made three recommendations aimed at bringing CBP’s practices in line with Federal law and regulations and promoting efficient processing of undocumented aliens. CBP concurred with two of the recommendations and did not concur with one. CBP defended its decision to redirect undocumented aliens at seven ports citing the availability of operational capacity and resources and the need to maintain a discretionary balance between mission requirements at each port.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Carl Vinson VA Medical Center and multiple outpatient clinics in Georgia. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.The executive leadership team had worked together for five weeks prior to the OIG’s on-site visit. The leadership team had vacancies in three of the four key positions since the previous healthcare inspection. Survey results revealed opportunities for the executive team to improve employee satisfaction. Patient experience survey results were generally less favorable than Veterans Health Administration national averages. The OIG’s review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning data.The OIG issued 17 recommendations for improvement in seven areas:(1) Quality, Safety, and Value• Committee processes(2) Medical Staff Privileging• Professional practice evaluations• Provider exit reviews(3) Medication Management• Quality measure oversight(4) Mental Health• Suicide prevention training(5) Care Coordination• Goals of care conversations(6) Women’s Health• Women’s health primary care providers• Committee membership and attendance(7) High-Risk Processes• Reusable medical equipment inventory file• Standard operating procedures• Annual risk analysis• Eyewash station testing• Quality assurance monitoring• Reprocessing and storage area physical inspections• Competency assessments