Federal Reports

This report presents the results of our audit of the U. S. Postal Service’s oversight of Parcel Select.

The purpose of this report is to summarize the OIG’s oversight and investigative work involving Federal student assistance programs and operations over the past 6 FYs—FY 2019 through FY 2024 and to provide the office of Federal Student Aid (FSA) with context on historical areas of weakness involving internal controls. To identify common themes across internal control vulnerabilities identified during our audit work, we evaluated recommendations made in OIG reports to address those vulnerabilities and assessed their correlation with each internal control component. And, in this effort, we analyzed complaints received by the OIG Hotline specific to Federal student assistance programs and FSA operations to identify trends and fraud indicators, summarized investigative results related to student aid fraud, and assessed their correlation to internal controls. We also took a close look at a type of fraud that accounts for a large portion of our student aid fraud investigative caseload—student aid fraud rings.

The results of this effort are intended to provide context on historical areas of weakness and vulnerabilities in FSA’s internal controls identified through the OIG’s audit work and provide insight gleaned from the OIG’s investigative work on the importance of strengthening internal controls to help mitigate the risk of fraud in the Federal student assistance programs. By strengthening its internal controls, FSA can better ensure that Federal student assistance programs are carried out as required, achieve the desired results, and that vital Federal student aid assistance reach the intended recipients.

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Birmingham VA Health Care System.

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

The OIG issued four recommendations for improvement in two domains:
1. Environment of care
• Separation of clean and dirty equipment and supplies
• Clean and safe environment
• Communication with sensory-impaired veterans
2. Patient safety
• Identify opportunities for improvement, implement action plans, and evaluate actions for sustained improvement

The VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection at the Tuscaloosa VA Medical Center (facility) in Alabama to evaluate the status of patient safety program deficiencies identified in a 2023 OIG report and Veterans Integrated Service Network (VISN) 7’s oversight of the facility’s patient safety program. Additionally, the inspection evaluated actions taken to address deficiencies in the community living center (CLC) regarding residents at risk for elopement identified in a 2022 OIG report.
In contrast to previous findings, the OIG found that the facility’s patient safety program complied with VA-mandated standards. The OIG’s analysis of facility patient safety data showed the patient safety manager appropriately accepted or rejected event reports; considered significant safety events for root cause analysis; and completed eight annually required patient safety analyses for fiscal year 2023.
While the VISN patient safety officer’s oversight of patient safety programs improved, the OIG identified the need for qualitative analysis of patient safety data, which is essential to assess the impact and effectiveness of VISN patient safety programs and develop effective actions plans.
Facility leaders addressed the deficiencies identified in the 2023 and 2022 OIG reports and determined actions taken by the facility leaders resulted in a facility culture where patient safety has become paramount. The OIG concluded that a commitment to continue to administer a high-quality patient safety program was evident in facility leaders’ actions.
The OIG determined that the facility resolved previous concerns regarding the safety and security of the residents in the CLC as well as implemented a review process to ensure electronic health record documentation for residents at risk for elopement was consistent with facility policy.
The OIG made three recommendations to the VISN Director related to the patient safety officer’s qualitative reviews of patient safety data.