Federal Reports

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The VA Office of Inspector General (OIG) conducted a healthcare inspection that assessed whether (1) a research study cardiologist provided follow-up cardiac care to a research patient; (2) a cardiology fellow failed to provide follow-up care and correctly interpret electrocardiograms; (3) the Subcommittee on Research Safety and Institutional Review Board failed to ensure adherence to a research plan; and (4) stress-test laboratory procedure instructions were inconsistent. A research patient had a positive stress-test result. Follow-up studies were ordered only as part of the research study. The research cardiologist failed to initiate cardiac follow-up care or notify the patient or primary care provider of positive stress-test results. The OIG found that the cardiology fellow provided follow-up care for patients with positive stress tests, but the OIG was unable to determine if the fellow had difficulty interpreting electrocardiograms. The OIG determined that supervising providers were involved with the fellow’s patient encounters. The Subcommittee on Research Safety and Institutional Review Board failed to ensure a research team’s adherence to the research plan related to notification of primary providers of their patients’ enrollment in the study. The OIG found that primary providers were inconsistently alerted. The OIG identified inconsistencies between instructions provided to cardiology fellows and the protocol used by facility staff for a stress-test laboratory procedure. The stress-test laboratory protocol did not include elements required by facility policy for establishing internal policy and standard operating procedures. The OIG made six recommendations related to ensuring research providers take action on stress-test results; conducting a retrospective review of enrolled patients’ result notifications and follow-up care; providing disclosure to the patient’s family; performing research oversight of the study plan to ensure communication of patient enrollment in the study to primary providers; and reviewing the stress-test laboratory educational material.

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For our audit of National Oceanic and Atmospheric Administration’s (NOAA’s) Joint Polar Satellite System (JPSS) program, our objective was to assess the cost, schedule, and technical performance of the Program’s spacecraft acquisition and development efforts. Specifically, we sought to (1) determine the extent to which cost and schedule changed from the original Program baselines, and (2) identify changes and challenges to the Program’s technical baseline. We found that, from March 2015 to November 2019, the cost of the JPSS-2 spacecraft firm-fixed-price contract increased by $28.6 million—or 12 percent—to $273.4 million, and the schedule for completing the spacecraft had been delayed 14 months. We identified several technical performance issues that contributed to the cost increase and schedule delays. Notably, completing development of field programmable gate arrays (FPGAs) in the payload interface electronics continues to be a major challenge towards finalization of the JPSS-2 spacecraft.

For our audit of the U.S. Census Bureau’s (the Bureau's) Census Questionnaire Assistance (CQA) operation -- in support of our oversight role over the planning and implementation of the 2020 Census -- our audit objectives were to determine how previous internal assessments informed the operation, how the CQA contract was planned, and how its costs were managed. Specifically, we sought to (1) determine whether the Bureau (a) implemented effective internal controls for controlling the cost of the CQA contract and (b) sufficiently supported the workloads and cost drivers used to estimate the CQA contract cost; and (2) determine whether the Bureau will be able to inform the 2020 Census CQA operation by utilizing lessons learned during the 2010 Census, the 2017 Census Test, and the 2018 End-to-End Census Test.Our testing did not identify significant deficiencies in the Bureau’s internal controls over how CQA contractor invoices are processed. Our testing of a sample of monthly contractor invoices from July 2016 to July 2018, specifically for labor charges and overhead costs, found that the costs charged were in line with the contract’s negotiated rates. Additionally, the Bureau was generally able to support the workloads and cost drivers for the CQA contract costs based on an independent government cost estimate dated February 18, 2016, which was prior to the contract award. We found that key assumptions such as contact center employee labor, facility space costs, workspace allocations, staffing ratios, and the number of calls received per customer service representative, were supported. However, we found issues with the internal controls used to manage the CQA contract, specifically performance, and the resolution of lessons learned from previous tests.

The Grants Oversight and New Efficiency (GONE) Act, P.L. 114-117, enacted on January 28, 2016, established mandatory reporting requirements for Federal Departments and Inspectors General Offices related to grant awards and cooperative agreements expired for 2 or more years that have not been closed out. GONE Act section 2(c) requires Inspectors General of Departments with greater than $500 million in annual grant funding to conduct a risk assessment of their Departments' grant closeout processes.