Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine how surgical instruments that were not suitable for service (nonconforming instruments) were used during a patient procedure at the Carl Vinson VA Medical Center (facility) in Dublin, Georgia. The OIG identified Sterile Processing Service (SPS)-related deficiencies as well as a continuation of previously identified deficiencies.

The OIG determined that SPS and operating room staff failed to remove nonconforming surgical instruments from a rectal tray that was used during a patient procedure. Moreover, the OIG found additional surgical instruments in nonconforming condition and that, contrary to policy, the reprocessing and use of nonconforming instruments was a permitted practice at the facility.

Additionally, facility leaders failed to establish a preventative maintenance program for the sharpening, repair, or replacement of surgical instruments prior to May 30, 2024.

The OIG also identified a continuation of previously identified deficiencies that included: the failure of facility leaders to fully implement an electronic surgical instrument tracking system known as CensiTrac, address concerns of the CensiTrac coordinator’s performance, and resolve concerns related to the intended use of an SPS conference and training room. Frequent changes in staff assigned to leadership positions, along with leaders’ failures identified above, likely contributed to the continued SPS deficiencies.

The OIG made two recommendations to the Facility Director related to ensuring staff’s compliance with identification and disposition of nonconforming surgical instruments and training operating room staff to recognize nonconforming surgical instruments. The OIG made three recommendations to the Veterans Integrated Service Network Director related to reviewing patients potentially affected by nonconforming instruments, evaluating whether administrative action is warranted for individuals regarding SPS deficiencies at the facility, and performing oversight of the facility’s implementation of facility-level action plans and sustainability of identified outcomes. 

We contracted with Williams, Adley & Company-DC, LLP (Williams Adley) to examine the effectiveness of the CFTC’s ERM process as well as its maturity. Williams Adley conducted the audit in accordance with Generally Accepted Government Auditing Standards (GAGAS) and is responsible for the attached audit report and the conclusions expressed therein.1 The OIG monitored the auditor’s progress throughout the performance audit and reviewed the respective audit report and related documentation.

The Veterans Health Administration (VHA) Grant and Per Diem (GPD) program funds community-based transitional housing for veterans experiencing homelessness. An OIG administrative investigation examined VHA’s oversight of the Veterans Village of San Diego (VVSD), a GPD program grantee providing drug treatment and other services. 

The OIG found that staff at the VA San Diego Healthcare System (the VA facility) responsible for local oversight of VVSD were aware that in 2021 and through most of 2022, issues with drug sales by non-VA residents, drug use, and insufficient staffing increased risks to veterans co-located there. However, VA facility staff did not take timely or effective action to ensure VVSD remediated these issues. Local facility staff lacked important information related to residents at VVSD who were funded by non-VA entities. Also, a regional official responsible for GPD oversight did not provide adequate support. Finally, the OIG found that the GPD National Program Office could have provided clearer guidance on key issues, such as when certain grantee enforcement measures should be used and how to redress recurrent grant noncompliance issues.

The OIG followed up the initial investigation with a limited review of VHA oversight of VVSD through September 2024, prompted in part by reports that improvements may not have taken hold. The investigation revealed that issues related to veteran care and safety, and a lack of information about co-located non-VA residents, recurred or persisted at VVSD. 

VHA concurred with the OIG’s finding and five recommendations to improve governing policies, training, or other guidance, and appropriate follow-up for GPD-funded residents at VVSD who lost access to drug treatment services there. VHA provided acceptable action plans and completion timelines. The OIG will monitor VA’s progress until sufficient documentation has been received to close the recommendations as implemented.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General performed this audit pursuant to the Hazardous Waste Electronic Manifest Establishment Act. The Act requires the EPA to prepare and the OIG to audit the accompanying financial statements of the EPA’s Hazardous Waste Electronic Manifest System Fund.

Summary of Findings

We rendered an unmodified opinion on the EPA’s fiscal years 2023 and 2022 Hazardous Waste Electronic Manifest System Fund, known as the e-Manifest Fund, financial statements, meaning that the statements were fairly presented and free of material misstatement. We did not identify any matters that we consider to be material weaknesses or significant deficiencies in the fund.

A former executive of a Chicago-area non-profit organization has pleaded guilty to a federal fraud charge for her role in misappropriating $1.8 million intended to support the charity’s work with underprivileged youth.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the Edward P. Boland VA Medical Center, part of the VA Central Western Massachusetts Healthcare System (facility) in Leeds.

The facility met some VHA requirements for inpatient mental health units, including providing the required amount of interdisciplinary programming for veterans and the completion of twice-yearly environment of care inspections. The inpatient unit included some aspects of a recovery-oriented physical environment, such as soft night lighting in the nurses’ station and veterans’ rooms.

Electronic health record reviews indicated most veterans were involved with the interdisciplinary treatment team in treatment planning, and veterans had documented safety plans. However, some records did not include evidence of timely suicide risk screenings, and discharge instructions were difficult to understand, lacking important details for appointment follow-up and medication management.

The facility did not have an established local mental health executive council or an interdisciplinary safety inspection team during the review period. The facility’s admission policy did not include processes for the admission of veterans on an involuntary hold. The facility leaders lacked formal processes to monitor and track compliance with involuntary commitment state laws.

The OIG identified environment of care deficiencies such as the unit’s sally port entrance doors were not synchronized; the inpatient unit had unweighted, unsecured chairs in a group room; and facility staff did not have a policy that addressed the use of a restraint chair. Additionally, many staff did not have evidence of completed environment of care or suicide prevention trainings. 

The OIG issued 16 recommendations to facility leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit and beyond.

We have reviewed the system of quality control for the audit organization of the National Railroad Passenger Corporation (Amtrak) Office of Inspector General (OIG) in effect for the year ended September 30, 2024. A system of quality control encompasses Amtrak OIG’s organizational structure, and the policies adopted, and procedures established to provide it with reasonable assurance of conforming in all material respects with Government Auditing Standards1 and applicable legal and regulatory requirements. The elements of quality control are described in Government Auditing Standards. 

In our opinion, the system of quality control for the audit organization of Amtrak OIG in effect for the year ended September 30, 2024, has been suitably designed and complied with to provide Amtrak OIG with reasonable assurance of performing and reporting in conformity with applicable professional standards and applicable legal and regulatory requirements in all material respects. 

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Central Western Massachusetts Healthcare System in Leeds. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued one recommendation for improvement in one domain:
1.    Environment of care
   •    Leaders assess storage locations outside of standard supply rooms and implement a process to ensure staff remove expired supplies