Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Ralph H. Johnson VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 25 employees. The Facility has generally stable executive leadership and active engagement with employees and patients as evidenced by satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to maintain Quality of Care and Efficiency metrics likely contributing to the “5-Star” rating. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued four recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: (1) Environment of Care • Participation in environment of care rounds • Cleanliness of floors in patient care areas • Maintenance of patient care equipment in clinical areas (2) Women’s Health: Mammography Results and Follow-Up • Scanning of mammogram reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the John J. Pershing VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. The Facility has a relatively new leadership team, and the Chief of Staff position was vacant at the time of the OIG review. Despite this, the OIG noted that the Facility leaders were actively engaged with employees and patients and had implemented proactive programs to improve satisfaction scores. Organizational leaders supported patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected SAIL metrics within their scope of responsibility and should continue to take actions to sustain and improve performance of Quality of Care and Efficiency metrics contributing to the current “4-Star” rating. The OIG noted findings in one of the seven areas of clinical operations reviewed and issued two recommendations that are attributable to the Associate Director. The identified area with deficiencies is: Environment of Care • General cleanliness • Emergency power supply system inspection

The Office of the Inspector General reviewed TVA’s three operating system baselines and how they are applied to the tools used to deploy and manage TVA systems. In summary, we found TVA management aligned two of the three server operating system baselines with the identified best practices and had documentation to support any deviations. However, we found one of the three operating system baselines did not fully align with the identified best practices and was not completely applied to the tools used to deploy and manage TVA server configurations. TVA management agreed with the audit findings and recommendation.

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What We Looked AtWe reviewed the State of Nebraska's single audit report for the fiscal year ending June 30, 2017, in order to identify findings that affect directly awarded Department of Transportation programs. An independent auditor prepared the single audit report, dated March 19, 2018.What We FoundWe found that the report contained a subrecipient monitoring finding that needs prompt action from the Federal Transit Administration's (FTA) management.RecommendationsWe recommend that FTA ensures that State complies with the subrecipient monitoring requirements. We also recommend that FTA recovers $99,226 from the State, if applicable.

The Fort Peck Assiniboine and Sioux Tribes (known collectively as the Fort Peck Tribes) are federally recognized Native American tribes located in Montana. For Federal fiscal years (FYs) 2011 through 2015, the Fort Peck Tribes did not administer $436,765 of Low-Income Home Energy Assistance Program (LIHEAP) grant funds in compliance with Federal laws, regulations, and guidance. These errors occurred because the Fort Peck Tribes did not have policies and procedures or other internal controls in place to prevent the errors. The improperly administered LIHEAP grant funds could have been used to provide eligible households additional benefits, or the Fort Peck Tribes could have used them for other purposes such as crisis situations, residential weatherization, or energy-related home repairs.

What We Looked AtWe performed a quality control review (QCR) on the single audit that Macias Gini O'Connell LLP (MGO) performed for the Riverside County Transportation Commission's (Commission) fiscal year that ended June 30, 2017. During this period, the Commission expended approximately $438 million from the U.S. Department of Transportation's (DOT) grant programs. MGO determined that DOT's major programs were the Transportation Infrastructure Finance and Innovation Act program and the High-Speed Rail Corridors and Intercity Passenger Rail Service Capital Assistance program.Our QCR objectives were to determine whether (1) the audit work complied with the Single Audit Act of 1984, as amended, the Office of Management and Budget's Uniform Guidance, and the extent to which we could rely on the auditors' work on DOT's major programs; and (2) the Commission's reporting package complied with the reporting requirements of the Uniform Guidance.What We FoundMGO's audit work complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT's major programs. In addition, we found nothing to indicate that MGO's opinion on each of DOT's major programs was inappropriate or unreliable. However, we identified deficiencies in the Commission's reporting package that required correction and resubmission.

In violation of the housing assistance payment contract’s conflict-of-interest requirements, the former executive director of the Housing Authority of the City of Beeville, TX, executed housing assistance payment contracts on behalf of the Authority with her brother and sister. The former executive director did not fully disclose the conflicts-of-interest and had not sought a waiver from HUD’s Office of Public and Indian Housing until the OIG’s review occurred. As a result, both siblings received housing assistance payments as landlords, and the Authority paid them $31,555 for ineligible housing assistance payments.On June 21, 2018, the Office of Program Enforcement executed a settlement agreement showing that HUD had filed a complaint against the former executive director and her siblings under the Program Fraud Civil Remedies Act of 1986, for causing false claims to be made in HUD’s Housing Choice Voucher Program. The respondents agreed to pay HUD $40,000 to settle the false claim allegations. The agreement required an initial payment of $13,320, 53 monthly payments of $500, and a final payment of $180. The settlement was not an admission of liability or fault on the part of any parties.

This report presents the results of our self-initiated audit of Local Purchases and Payments – Otisville, MI, Main Post Office. The Otisville Post Office is located in the Detroit District of the Great Lakes 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 were valid and properly supported at the Otisville, MI, Main Post Office.