Federal Reports

The Office of Inspector General assessed efforts of the Center for Advancement of Science in Space (CASIS) to manage non-NASA research on the U.S. portion of the International Space Station known as the National Lab.

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We received hotline complaints detailing concerns related to Spectrum 4’s acquisition and performance. We initiated a limited scope review to determine the legitimacy and severity of these issues. We substantiated some of the issues, and they warrant management’s attention. Specifically, we found the deployment of Spectrum 4 resulted in increased errors/variances, which required PBGC to release ten versions in attempts to fix the issues causing the errors. We also found that the deployment of Spectrum 4 resulted in slower day-to-day functioning of the system. This slowness has impacted users’ ability to complete tasks and frustrated users. In response to the issues we substantiated, we recommend that management perform and document an Integrated Product Team led “lessons learned”.

This report provides the results of our review of the Centers for Disease Control and Prevention (CDC) detailed accounting submission, which includes the table of Drug Control Obligations, related disclosures, and management's assertions for the fiscal year ended September 30, 2017. We also reviewed the Performance Summary Report, which includes management's assertions and related performance information for the fiscal year ended September 30, 2017.

Carolinas Medical Center (the Hospital), located in Charlotte, North Carolina, complied with Medicare billing requirements for 157 of the 240 inpatient claims that we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 83 claims, resulting in net overpayments of $331,831 for the audit period. On the basis of our sample results, we estimated that the Hospital received overpayments of at least $1.7 million for the audit period. These errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors.

This report provides the results of our review of the Health Resources and Services Administration (HRSA) detailed accounting submission, which includes the Table of Drug Control Obligations, related disclosures, and management's assertions for the fiscal year ended September 30, 2017. We also reviewed the Performance Summary Report, which includes management's assertions and related performance information for the fiscal year ended September 30, 2017.

This report provides the results of our review of the Substance Abuse and Mental Health Services Administration (SAMHSA) detailed accounting submission, which includes the Table of Drug Control Obligations, related disclosures, and management's assertions for the fiscal year ended September 30, 2017. We also reviewed the Performance Summary Report, which includes management's assertions and related performance information for the fiscal year ended September 30, 2017.

This report provides the results of our review of the National Institutes of Health (NIH) detailed accounting submissions, which include the tables of Fiscal Year 2017 Actual Obligations, related disclosures, and management's assertions for the fiscal year ended September 30, 2017. We also reviewed the Performance Summary Report, which includes management's assertions and related performance information for the fiscal year ended September 30, 2017.

This report provides the results of our review of the Indian Health Service (IHS) detailed accounting submission, which includes the table of Drug Control Obligations, related disclosures, and management's assertions for the fiscal year ended September 30, 2017. We also reviewed the Performance Summary Report, which includes management's assertions and related performance information for the fiscal year ended September 30, 2017.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Minneapolis VA Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home (CNH) Oversight. OIG provided crime awareness briefings to 26 employees.The facility has generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supports patient safety, quality care, and other positive outcomes. The senior leadership team was knowledgeable of insightful and important metrics that reflect upon their leadership qualities and activities taken to improve or sustain performance of selected metrics. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors.OIG noted findings in the six areas of clinical operations reviewed and issued 18 recommendations. The identified areas with deficiencies are:(1) QSV• Implementation of Peer Review Committee actions• Completion of utilization management reviews and documentation of decisions• Annual patient safety report• Committee meeting minutes(2) Medication Management: Anticoagulation Therapy• Inclusion of required elements in facility policy• Quality assurance data• Staff competency assessments(3) Coordination of Care: Inter-Facility Transfers• Inclusion of required elements in facility policy• Documentation for inter-facility transfers(4) EOC• EOC rounds frequency and attendance• Mental health unit staff and Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Moderate Sedation• History and physical examination and pre-sedation assessment components• Provision and documentation of informed consent • Performance of timeouts(6) Long-Term Care: CNH Oversight • Oversight committee participation• Monthly cyclical clinical visits