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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
U.S. Agency for International Development
Examination of Costs Claimed for Natural Resources Consulting Engineers for the Two Fiscal Years Ended December 31, 2016 and 2017
The Office of Inspector General (OIG) provides oversight to U.S. Department of Agriculture (USDA) programs and operations to help ensure that USDA is able to provide the best possible service to the public and American agriculture. OIG focuses its efforts to advance the value, safety and security, and integrity of USDA programs. In providing such oversight, OIG makes recommendations to address agency programs and core management functions that may be vulnerable to waste, fraud, abuse, and mismanagement. These vulnerabilities can affect USDA’s ability to achieve its mission. Since the Reports Consolidation Act of 2000, OIG has annually reported on the Department’s progress in addressing its most critical management challenges. The COVID-19 pandemic, and USDA’s increased responsibilities for program delivery, have made addressing these challenges even more important.
The VA Office of Inspector General (OIG) conducted a healthcare inspection after receiving a referral from OIG inspectors regarding facility leaders’ response to a report that a urologist had severe hand tremors and possibly low vision. The OIG identified two adverse clinical outcomes in 121 of the urologist’s surgical patients, neither of which required an increased level of care and did not result in long-term impact. The OIG determined the two complications were appropriately managed by the urologist, reported through the patient safety reporting system, and acted upon. Facility leaders failed to adequately oversee the urologist’s performance by not formally evaluating a report of the urologist’s physical impairments that could have posed a risk to patient safety. The facility conducted management reviews of the urologist, but deficiencies were identified in the processes used. Failures in facility leaders’ privileging processes led to delays in removing the urologist’s privilege to perform open procedures and a failure to inform the urologist of active privileges. Facility leaders were noncompliant with VHA directives that require reporting adverse privileging actions to the National Practitioner Data Bank and reporting patient safety concerns to state licensing boards. Consequently, patient safeguards intended to be achieved through reporting did not occur. Frequent personnel changes in facility-leader positions may have contributed to failures in oversight, privileging, and practitioner reporting processes. The noncompliance with facility and VHA policies likely occurred due to poor communication regarding the urologist’s practice and privileging status, a lack of knowledge of position responsibilities, and inexperienced support staff. The deficiencies found in the focused professional practice evaluation processes and National Practitioner Data Bank reporting were consistent with issues previously identified by the OIG. Duplicative recommendations were not made regarding these issues. The OIG made six recommendations to the Veterans Integrated Service Network 7 and facility directors.
Management Advisory: Notification of Concerns Identified in the Federal Bureau of Investigation’s Contract Administration of a Certain Classified National Security Program