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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Department of Veterans Affairs
Review of Alleged Adverse Effect on Patient Care Due to Removal of a Computer-Assisted Survey Instrument
In September 2015, OIG received an allegation that the Office of Information and Technology (OIT) removed the Prescription Opioid Documentation and Surveillance (PODS) application from a VA server at the Northern California Health Care System (NCHCS) Pain Management Clinic. The complainant alleged the removal was potentially harmful to veterans who were put at increased risk of accidental overdose. We substantiated the allegation that OIT removed PODS. PODS used medical and mental health questionnaires to obtain patient information from patients prior to face-to-face evaluations with clinicians. According to the NCHCS Chief of Staff, PODS was “not a standard of care.” In addition, clinicians told us PODS was not necessary for prescribing and tracking opioids. Clinicians reported they clinically evaluated and assessed patients’ to determine the required level of monitoring and long-term opioid therapy. Because PODS was not needed to meet an appropriate standard of care, and clinicians reported they could provide requisite care without PODS, we concluded its removal did not put veterans at increased risk of accidental overdose. Although not part of the allegation, we found OIT failed to protect the integrity of VA’s enterprise and the security of the information it stored by allowing PODS’ use. PODS was started as a research project in 2006. After the research ended in 2012, clinicians continued to use PODS until it was removed in July 2015. However, PODS was an unsupported Class III software that did not meet system requirements, which created an unnecessary risk that veterans’ sensitive information could be accessed. These security concerns existed because OIT Region 1 staff failed to follow their standard operating procedures for the assessment and removal of Class III software.
We issued 12 audit recommendations in the 2013 audit report of Peace Corps/Zambia, all of which the post and the Office of the Chief Financial Officer implemented and we closed. However, during the follow-up audit we noted that the internal controls over the post’s financial and administrative operations required significant improvement to comply with agency policies and applicable Federal laws and regulations. Our report contains 21 recommendations directed to both the post and headquarters. At the post, our recommendations include implementing controls over fuel purchase and use, imprest funds, staff health insurance, disbursements, and security clearance for staff. We also recommend putting in place a contract with the auctioneer and enhancing controls over Volunteer allowances. We recommend that headquarters issue guidance on implementing internal controls over fuel purchase and use.
We determined that 9,389 aliens identified as having multiple identities had received an immigration benefit. When taking into account the most current immigration benefit these aliens received, we determined that naturalization, permanent residence, work authorization, and temporary protected status represent the greatest number of benefits, accounting for 8,447 or 90 percent of the 9,389 cases. Benefits for the remaining 10 percent of cases include applications for asylum and appeals to immigration court decisions. USCIS has drafted a policy memorandum, Guidance for Prioritizing IDENT Derogatory Information Related to Historical Fingerprint Enrollment Records, outlining how it will review cases of individuals with multiple identities whose fingerprints were uploaded into IDENT through HFE. We did not make any recommendations.
The Fiscal Year 2018 – 2020 Strategic Plan includes the long-range goals and objectives designed to enhance OIG oversight in support of the Peace Corps and its three goals.
This is our final report on the Department’s top management and performance challenges for fiscal year (FY) 2018. The top management and performance challenges we reported on last year remain critical issues facing the Department. However, we have revised our discussion to reflect the Department’s progress, changing priorities, and emerging risks:Challenge 1: Delivering a Timely 2020 Census That Maintains or Improves Data Quality but Costs Less Per Household Than the 2010 CensusChallenge 2: Ensuring the Continuity of Environmental Satellite ObservationsChallenge 3: Securing Department Systems and InformationChallenge 4: Deploying a Nationwide Public Safety Broadband NetworkChallenge 5: Efficiently and Effectively Enforcing Laws That Promote Fair and Secure TradeChallenge 6: Modernizing the Department’s Legacy IT Systems and Improving Data QualityChallenge 7: Implementing Processes to Improve Management of the Department’s Contracts, Grants, and Cooperative Agreements
The Administration for Children and Families Region VI Did Not Always Resolve Head Start Grantees' Single Audit Findings in Accordance With Federal Requirements
The Administration for Children and Families (ACF) had a process in place to ensure that Head Start grantees took corrective action on A-133 audit findings. Head Start grantees are required to have Single Audits conducted in accordance with Office of Management and Budget Circular A 133 (also known as A-133 audits) for fiscal years beginning before December 26, 2014. However, for Region VI Head Start grantees that submitted audit reports to the Federal Audit Clearinghouse (FAC), ACF did not always resolve recurring audit findings in accordance with Federal requirements and ACF policies and procedures. Specifically, ACF did not issue Audit Determination Letters (letters) for 20 of the 31 audit reports we reviewed within 6 months after receiving the reports. In addition, although ACF provided the grantees with letters stating that the corrective actions planned or taken should prevent recurrence of the findings, ACF did not establish specific dates for grantees to correct all deficiencies noted in the audit reports. Finally, ACF did not always follow up with grantees to ensure that they actually took corrective actions to resolve audit findings. The prompt resolution of audit findings helps ensure that Federal funds are effectively and efficiently used to carry out the activities for which they were authorized.