Federal Reports

We investigated allegations that two National Park Service (NPS) managers violated contracting regulations and procedures by using the Standard Form 182 (SF-182), which is meant to fund standardized training, to pay a company for extended work on an internal NPS training website. We also investigated allegations that NPS employees improperly hired NPS retirees and then re-issued or re-activated their Personal Identity Verification (PIV) cards.We found that the two NPS managers, who oversaw aspects of NPS training programs, improperly used the SF-182 to pay a company $1,041,117 to develop and maintain an internal training website, circumventing contracting regulations. The two NPS managers have since left the agency.We also found that one of the managers retained his PIV card after retiring and had another employee re-enable the card after he left Federal service, in violation of departmental policy. We also discovered a separate instance in which an NPS retiree performed fiscal and budget-related services for an NPS training center without a contract. The NPS retiree received a new PIV card under the guise of an unrelated contract.

The OIG investigated an allegation that an employee with the Office of the Assistant Secretary for Indian Affairs (AS-IA) may have improperly used entities that he owned or had a financial interest in to perform work at the U.S. Department of the Interior (DOI).We found that the employee was involved in choosing two unregistered entities with whom he or other DOI staff had personal relationships and repeatedly paid them with a charge card, rather than establish a contract as required. The employee violated DOI policy and Federal regulations by misusing his Government charge card; asking for and receiving cash from the entities while they performed work for the DOI; issuing numerous payments to the entities with no supporting documentation; and submitting altered invoices during an internal charge card review as support for payments he made. We also found the employee personally received funds from the DOI for a private group he operated, and he did not file a financial disclosure as required by his position.The U.S. Department of Justice declined prosecution and the employee left Federal service.

The VA Office of Inspector General (OIG) conducted this review to determine whether Veterans Benefits Administration (VBA) decision makers accurately completed disability evaluations for veterans’ service-connected heart disease. The OIG estimated VBA decision makers incorrectly evaluated about 12 percent of claims for heart disease between November 1, 2018, and April 30, 2019. Of those, about 870 resulted in improper payments totaling at least $5.6 million. VBA decision makers inappropriately evaluated heart disease using information from disability benefits questionnaires filled out either by VA or contracted medical providers. Decision makers also made other inaccurate decisions on claims. The OIG determined that the disability benefits questionnaire format contributed to the inappropriate evaluations of veterans’ heart conditions. The system-generated instructions for the questionnaire prompted unclear medical statements. VBA decision makers did not consistently ask for the clarification they needed to make accurate disability determinations. The OIG made three recommendations for improving the handling of disability benefits questionnaires for heart diseases to ensure they are properly filled out with unambiguous and consistent information. The OIG made no recommendation on the inaccurate claims decisions because the review team did not identify a common trend or pattern for these errors.

The VA Office of Inspector General (OIG) assessed an allegation that providers permitted an individual with no legal authority to make medical decisions on behalf of a patient. The patient had a three-week medical and mental health hospitalization with repeated episodes of confusion, agitation, and combative behavior. The patient was transferred to hospice care and died five days later. The OIG substantiated the patient’s neighbor had no legal authority but made medical decisions. The OIG noted clinical and patient rights deficiencies and reviewed facility leaders’ evaluation of the deficiencies in the patient’s care. Facility staff did not take the required appropriate steps to identify and confirm the eligibility of this surrogate. Staff searched the patient’s belongings and records, but they did not review other VA records. Three days after the patient’s death, administrative staff located a family member from VA benefits records. The OIG determined that records did not contain sufficient documentation of physicians’ clinical assessments to support diagnoses and treatment decisions. Clinical communication and collaboration were inconsistent, insufficient, and negatively impacted the patient’s continuity and quality of care. Providers did not consistently document medication monitoring and oversight activities to ensure safe patient care. The OIG concluded the patient’s transfer to hospice was completed without fully pursuing other diagnoses and treatment options and staff did not ensure the patient’s rights were upheld regarding involuntary admission and behavioral restraints. Facility leaders did not complete a thorough quality of care review to understand the reasons for the patient’s atypical hospital course and outcome. The OIG made 15 recommendations to the Facility Director related to the patient’s decisional capacity, surrogate identification, medical assessments, medication management, and hospice admission. Other areas of focus included patient rights, quality management processes, and institutional disclosure.

A majority of U.S. customers are concerned about the environmental impact of deliveries and many factor in these concerns when choosing a delivery company.To respond to customers’ expectations the Postal Service — like competitors and international posts — could consider offering optional carbon compensation offsets for its letters and parcels, as well as reusable packaging solutions.

The objective for this management advisory report was to monitor and assess how the company is using CARES Act funds and the controls it has in place to accurately account for and report on them.The company experienced a sharp drop in ridership and passenger revenues in March 2020 as a result of the coronavirus pandemic. The company’s response included aggressive cost-cutting actions such as cancelling some of its train service and reducing management pay and retirement benefits. Despite these actions, the company projected that revenues would still not cover its reduced costs and requested assistance from Congress. Congress responded by providing the company with $1.018 billion through the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) to “prevent, prepare for, and respond to” the coronavirus pandemic.On April 16, 2020, we began an audit to monitor and assess how the company is using CARES Act funds and the controls it has in place to accurately account for and report on them. So far, the company’s initial steps to use, account for, and report on the CARES Act funds are encouraging. By its actions, the company appears committed to providing transparency and demonstrating fiscal responsibility over its use of these funds. We identified three areas where additional focus could reduce risks. Going forward, a focus on providing more transparent data on how changes in service will affect state costs will help states as they develop their own budgets. In addition, a more-timely verification of pandemic-related expenses will help demonstrate that the company is being a responsible steward of taxpayer dollars. This is especially important considering that the company has requested $1.475 billion in supplemental funding for FY 2021 to mitigate expected shortfalls in passenger revenue. Finally, ensuring that adequate controls are in place to safeguard scarce pandemic-related materials and equipment throughout all links in the supply chain will ensure that these products are available to support the safety and health of the company’s workers and the traveling public.