Federal Reports

The VA Office of Inspector General (OIG) initiated an inspection to assess allegations regarding concerns with cardiology procedures at the facility and evaluated facility leaders’ responses to reports of deficiencies in the Cardiac Catherization and Electrophysiology Laboratories. The OIG substantiated that complications occurred in 13 of 22 patients who underwent cardiac procedures at the facility, two of which resulted in death. The OIG team reviewed the electronic health records of the 13 patients for adverse clinical outcomes and determined that the complications, including the deaths, were not due to deficiencies or failure to follow Veterans Health Administration policy, and were consistent with known risks associated with cardiac procedures. The OIG also determined that, in response to the death of the patient who underwent a cardiac catheterization procedure, facility leaders followed policy and initiated quality reviews. The OIG did not substantiate that an anesthesiologist had concerns about the Cardiac Catheterization Laboratory. However, the OIG found that the Chief of Anesthesiology had a concern about the pre-procedural workup of the subject patient, which facility leaders addressed. The OIG found that the Cardiopulmonary Resuscitation Committee meeting minutes lacked a way to identify a specific patient code event; however, a June 18, 2019, OIG Comprehensive Healthcare Inspection Program team recommended the committee review each resuscitative episode; therefore, this report will make no further recommendations related to the committee. The OIG substantiated that the Acting Chief of Staff was aware of issues in the Cardiac Catheterization Laboratory but did not substantiate that no follow-up action occurred. The Acting Chief of Staff was aware of the eight other patients identified in the allegation and the subject patient’s death and partook in reviews. The OIG did not substantiate that a cardiologist was not present during procedures or that fellows performed procedures independently. The OIG made no recommendations.

This report presents the results of our self-initiated audit of Local Purchases and Payments: Miscellaneous Services – Ellensburg, WA, Main Post Office (MPO). The Ellensburg MPO is in the Seattle District of the Western Area. This audit was designed to provide U.S. Postal Service management with timely information on potential financial control risks at Postal Service locations. Our objective was to determine whether local purchases and payments made at the Ellensburg MPO were valid and properly supported and processed.

Our objective was to review select mail delivery and customer service operations at the Chatsworth Post Office in Chatsworth, CA. We reviewed delivery metrics including the number of routes and carriers, mail arrival time, amount of reported delayed mail, package scanning, distribution up-time, and carriers’ return-to-office time. During our site visits on January 14-15, 2020, we reviewed unit safety and security procedures, mail conditions, and Voyager card and arrow lock key security procedures. We analyzed the scan status of mailpieces at the carrier cases and in the “Notice Left” area and interviewed unit management and employees.

We reviewed the oversight of opioid prescribing and the monitoring of opioid use in Kentucky. This factsheet shows Kentucky's responses to our questionnaire covering five categories related to its approach to addressing the opioid epidemic: policies and procedures, data analytics, programs, outreach, and other efforts.

The Office of Inspector General examined NASA’s management of the data centers it uses to manage Earth science data collected from satellites, aircraft, field measurements, and other Agency programs.

This audit is part of a series of hospital compliance audits. Using computer matching, data mining, and other data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2016, Medicare paid hospitals $170 billion, which represents 46 percent of all fee-for-service payments for the year.

For our final report on the audit of the Bureau of Industry and Security (BIS) regarding foreign end users and exports, our objective was to assess the effectiveness of BIS’ efforts to ensure foreign end users are suitable to receive and use controlled U.S. exports in accordance with the Export Administration Regulations. As a result of audit planning, we decided to focus on assessing BIS’ plan to target end-use checks (EUCs). Specifically, we sought to identify whether BIS had criteria to target EUCs and assess how well it adhered to them in FYs 2015–2017.We found that BIS (1) is unable to adequately determine whether EUCs met its targeting criteria and (2) did not fully screen export transactions that used the Strategic Trade Authorization license exception.