Federal Reports

The Federal Emergency Management Agency (FEMA) mismanaged the distribution of commodities in response to Hurricanes Irma and Maria in Puerto Rico. FEMA lost visibility of about 38 percent of its commodity shipments to Puerto Rico, worth an estimated $257 million. Commodities successfully delivered to Puerto Rico took an average of 69 days to reach their final destinations. Inadequate FEMA contractor oversight contributed to the lost visibility and delayed commodity shipments. FEMA did not use its Global Positioning System transponders to track commodity shipments, allowed the contractor to break inventory seals, and did not ensure documented proof of commodity deliveries. Given lost visibility and delayed shipments, FEMA cannot ensure it provided commodities to Puerto Rico disaster victims as needed to sustain life and alleviate suffering as part of its response and recovery mission. In addition, FEMA’s mismanagement of transportation contracts included multiple contracting violations and policy contraventions that ultimately led to contract overruns of about $179 million and at least $50 million of questioned costs. We made five recommendations that, if implemented, should improve FEMA’s management and oversight of its disaster response activities. FEMA concurred with four of the five recommendations. Recommendations 1 through 4 are considered open and resolved. Recommendation 5 is considered resolved and closed.

Previous Office of Inspector General (OIG) audits found that States had improperly paid Medicaid managed care entities capitation payments on behalf of deceased beneficiaries. We conducted a similar audit of the North Carolina Department of Health and Human Services, Division of Health Benefits, which administers the Medicaid program.Our objective was to determine whether North Carolina made capitation payments on behalf of deceased beneficiaries.

We determined significant amounts of overtime were worked by employees at some gas plants. Specifically, we determined 69 percent (221,517 hours) of the 318,903 hours of overtime was performed at 7 of the 17 plants. The overtime worked at these 7 plants was the equivalent of 51 full-time employees. We also determined some employees worked significant amounts of overtime. For example, we found 51 instances during fiscal years 2018 and 2019 where employees worked over 1,000 hours of overtime and 2 of these employees had nearly 2,000 hours of overtime in a single year. Additionally, we determined the Tennessee Valley Authority (TVA) may not be accurately capturing the effects of fatigue because (1) fatigue assessments are no longer required when significant overtime is worked and (2) fatigue data is not trended with health and safety data in TVA’s medical case management system.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the prior authorization drug request process. The OIG substantiated that the prior authorization drug request consult template included limited space for prescribers to enter treatment rationale and prescribers did not always know about an option to document unlimited supplemental information. The Pharmacy and Therapeutics Committee included adequate mental health representation; however, the relationship between the committee’s leaders and the mental health representative was problematic and noncollaborative. While the OIG did not determine that the prior authorization drug request or appeals process delayed treatment, a mental health prescriber may have contributed to one patient not receiving medications. Prescribers were unfamiliar with, or erroneously understood, the process for expediting an appeal and mental health prescribers modified their prescribing practices to avoid pharmacy processes. Since 2019, facility leaders were aware of, and did not effectively resolve, unprofessional communications between Mental Health and Pharmacy Services staff, including a mental health prescriber improperly documenting critical comments and disagreeing opinions within patients’ electronic health records. Further, Pharmacy Services staff and leaders sent disrespectful emails about Mental Health Service staff. The OIG substantiated that a pharmacist canceled medication orders without communicating with a patient; however, facility policy requires the requesting prescriber, not the pharmacist, to notify the patient of medication information. The OIG did not substantiate that pharmacists canceled medication orders without communicating with the requesting prescriber or that pharmacist reviewers denied a large number of prior authorization drug requests. The OIG made five recommendations to the Facility Director related to prescriber education, promotion of mental health prescribers’ pursuit of the most effective treatment plan, review of improper electronic health record entries and email, and evaluation of ways to improve workplace relationships.