Federal Reports

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements

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The VA Office of Inspector General (OIG) conducted a healthcare inspection to address care and process issues for an Emergency Department patient and out of operating room airway management processes (OOORAM). The OIG substantiated that an advanced practice registered nurse caused airway trauma while unsuccessfully attempting intubation. However, the bleeding was minor and of no lasting impact. OIG staff determined that the other aspects of the subject patient’s emergency care were appropriate. The OIG substantiated the advanced practice registered nurse did not document the failed intubation attempts in the patient’s health record. The OIG team concluded that the advanced practice registered nurse should have personally documented the procedure in the patient’s health record. The OIG substantiated that an Emergency Department provider documented a brief normal neurological examination and determined that this was adequate given the emergent circumstances. The OIG did not substantiate that the patient was inadequately sedated prior to receiving paralytics for the intubation. The OIG concluded that the patient received a sedative medication for seizures, which is also used for intubation. Furthermore, the patient was unresponsive and therefore did not likely need additional sedatives. The OIG found the facility was not in compliance with tracking competency assessments for OOORAM providers, and leaders addressed OOORAM issues when they became aware of deficiencies and were working to implement new processes for OOORAM provider privileging. The OIG team identified that providers’ credentialing information was not consistently uploaded into VetPro and determined Cardiopulmonary Resuscitation Committee minutes were lacking in documentation of discussion related to resuscitative events, data analysis, and actions proposed for improvements. OIG inspectors made seven recommendations related to OOORAM documentation, review of OOORAM policy, OOORAM training and competency, credentialing, VHA OOORAM policy implementation, documentation in VetPro, and committee review of resuscitative events.

The objective was to determine whether local purchases and payments made at the Houston, TX, Roy Royall Station were valid, properly supported and processed. To accomplish the objective, we interviewed unit personnel and Postal Service management. We also analyzed purchase and payment data and examined money order receipts and other payment supporting documentation for miscellaneous expense transactions that occurred from January 1 through March 31, 2019.

This report presents the results of our self-initiated audit of Meter Revenue Refunds – Fredericksburg, VA, Post Office. The Fredericksburg Post Office is located in the Richmond District of the Capital Metro Area. This audit was designed to provide Postal Service management with timely information on potential financial control risks at Postal Service locations. The objective of this audit was to determine whether meter refunds were valid, timely, and properly supported at the Fredericksburg Post Office.

The EPA OIG has identified a control issue concerning the EPA's annual process of confirming that its attorneys maintain an active bar membership.This report resulted from an investigation, rather than an audit or evaluation project.