Federal Reports

The OIG’s administrative investigation examined whether the deputy executive director of VA’s Office of Construction and Facilities Management (OCFM), during his tenure as acting executive director, failed to respond appropriately to a 2018 audit by the office’s Quality Assurance Service (QAS). The QAS audit found that an unsubstantiated assertion was used to justify a lease acquisition by OCFM’s Central Region Office. The audit was deemed a “special review,” for which the service lacks a governing policy. Consequently, there was no process to track the audit’s findings and recommendations, unlike routine compliance reviews. The deputy executive director took 11 months to respond to the audit and did so only to OCFM’s executive leadership, leaving some OCFM personnel with an impression that he had ignored it. Although the OIG did not find that the deputy executive director failed to respond to the audit, it determined that OCFM lacks a policy relating to special reviews and made a corresponding recommendation.The OIG also investigated whether the deputy executive director, while the acting executive director, falsely attested to the effectiveness of OCFM’s internal controls. The deputy executive director signed statements of assurance in 2019 per governing requirements, attesting that OCFM’s controls suffered from no material weaknesses. At a February 2020 meeting, he commented on concerns he had with OCFM’s controls and assessment process, which some attendees viewed as an admission of a past false statement. The deputy executive director’s interview responses, his contemporaneous statements, and an informal inquiry by his successor indicated that the February 2020 comments referred merely to nonmaterial weaknesses in OCFM’s controls and assessment process. Thus, the OIG did not substantiate that the deputy executive director made false statements.VA concurred with the OIG’s findings and its recommendation.

As required by the Federal Information Security Modernization Act of 2014 (FISMA), we reviewed the Agency’s information security program for fiscal year 2021 and reported the results to OMB.

The VA Office of Inspector General (OIG) conducted an inspection at the Southern Oregon Rehabilitation Center and Clinics in White City (facility) and Roseburg VA Health Care System (Roseburg) in Oregon to evaluate an allegation that a resident (resident 1) was admitted to the facility’s Mental Health Residential Rehabilitation Treatment Program (MH RRTP) despite not meeting admission criteria, was later transported to Roseburg for admission but was instead discharged to the community. Additional allegations were received that a second resident did not meet admission criteria and another resident was injured in the shower area. The OIG later learned about other residents who may not have met admission criteria and who fell in the shower area.The OIG did not substantiate that resident 1 was inappropriately admitted to the MH RRTP but found the resident’s discharge was not coordinated. The OIG determined the resident’s transport to Roseburg did not comply with policy. Resident 1 was assessed, determined to not meet Roseburg admission criteria, and discharged to the community.The OIG found that four of five residents reviewed met admission criteria. The OIG was unable to determine if the fifth resident met admission criteria, but found the resident should have been reevaluated after a change in medical status prior to admission.The OIG substantiated a resident was injured after falling while getting out of the shower and learned about two additional residents who fell in the shower area in the preceding 10 months. The OIG determined that facility leaders were aware of the falls but missed an opportunity to implement solutions in a timely manner.The OIG made five recommendations to the Facility Director related to the discharge template, discharges during regular business hours, transport of residents with behavioral flags, conducting medical evaluations, and a review of falls in the shower area.

Audit report in which independent public accounting firm presented an unmodified opinion on the Denali Commission’s fiscal year 2021 financial statements.

The objective was to determine to what extent FEMA followed Federal and departmental procedures and guidelines for awarding COVID-19 contracts to vendors in unusual and urgent circumstances.