Federal Reports

Our review found that the Peace Corps did not fully comply with applicable Federal requirements relating to cooperative agreements and lacked internal controls in making the award to Seed Global Health Services. Specifically, the Peace Corps did not have sufficient documentation to justify awarding the cooperative agreement without competition. This made the Peace Corps vulnerable to the perception of favoritism by obligating a total of approximately $7.5 million in Department of State funding to Seed Global Health Services. We found several weaknesses caused by insufficient controls: the lack of segregation of duties for a senior agency official, the lack of key policies governing cooperative agreements, poor file management and failure to obtain the necessary anti-lobbying certifications from Seed Global Health Services. This report makes five recommendations to help enhance controls over cooperative agreements.

The objective of our audit was to evaluate the Office of Special Education Programs’ (OSEP) implementation of its differentiated monitoring and support (DMS) component under the results driven accountability initiative. We found that OSEP needs to enhance its implementation of the DMS component under the results driven accountability initiative to help ensure that it plans and conducts DMS properly and consistently across all States. Specifically, OSEP did not have sufficient policies and procedures for how personnel should perform and document the four phases of DMS (1) performing organizational assessments of States, (2) designating engagement levels for States, (3) issuing notices and charts to States, and (4) conducting and documenting tasks and activities for the DMS areas. To implement DMS, OSEP changed the way it monitored States to a method that is based on OSEP’s assessment of States’ needs in meeting performance standards and complying with legal requirements. Our review of OSEP’s DMS documentation in the results and compliance areas for the 12 States included in our review showed that OSEP did not: (1) include applicable or consistent data to assess risk for 6 of the 12 State organizational assessments we reviewed; (2) notify 1 of the 12 States on the applicable factors that contributed to the DMS engagement level designation; or (3) document monitoring, technical assistance, or support activities properly or sufficiently for 11 of the 12 States we reviewed.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care at the Louis A. 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 (QSV); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Posttraumatic 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. At the time of the OIG site visit, the leadership team had been working together for nine months. Facility leaders were generally engaged with patients; working to improve employee satisfaction scores; and appeared to support efforts related to patient safety, quality care, and other positive outcomes. However, the presence of organizational risk factors—lack of identification, tracking, and reporting of sentinel events and disclosure of adverse events—may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and monitored. The leadership team should continue to take actions to improve care and maintain performance of selected Strategic Analytics for Improvement and Learning (SAIL) Quality of Care and Efficiency metrics likely contributing to the current “4-Star” rating. The OIG noted findings in five of the clinical operations reviewed and issued nine recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) QSV • Physician Utilization Management Advisors’ documentation of decisions • Interdisciplinary review of utilization management data (2) Credentialing and Privileging • Ongoing Professional Practice Evaluation processes (3) EOC • General safety • Emergency power testing and availability (4) Medication Management: CS Inspection Program • CS reconciliation • Verification of Orders (5) High-Risk Processes: Central Line-Associated Bloodstream Infections • Staff education