Federal Reports

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Texas Valley Coastal Bend Healthcare System in Harlingen. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued three recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Toxic exposure screenings
   2.    Patient safety
     •    Service-level workflows for test result communication
     •    Peer Review Committee meeting attendance

The OIG conducted an administrative investigation into allegations of misconduct by Judith Dawson, former Chancellor of the VA Acquisition Academy, in connection with an August 2023 acquisition training symposium held at a conference center hotel in Aurora, Colorado, and attended by over 1,200 contracting personnel.

The OIG found that Ms. Dawson knowingly accepted multiple impermissible gifts from the conference center and violated VA policy by improperly directing staff to solicit and accept gifts of sponsored social events at the symposium, purportedly on behalf of VA. The OIG also found that Ms. Dawson at times discouraged her executive assistant from raising questions or seeking guidance regarding potential ethical violations in connection with the symposium, which was contrary to legislative direction that supervisors are to foster an environment in which VA employees could express concerns. Further, the investigation revealed that Ms. Dawson did not report the spa services she received from the conference center as gifts on her annual public financial disclosure report for 2023, even though the value of the gifts exceeded the reporting threshold. Instead, Ms. Dawson indicated that she had no reportable gifts.

Due to Ms. Dawson’s retirement from VA, the OIG made no recommendations with respect to possible administrative action against her. However, the OIG recommended that VA determine whether any additional steps need to be taken regarding Ms. Dawson’s 2023 public financial disclosure based on the findings in this report. The OIG also recommended VA consider additional training on sponsorships for VA events and acceptance of free meals. VA concurred with the OIG’s recommendations and noted that it plans to issue a memorandum regarding whistleblower protections, direct the relevant senior executives to complete conference policy training and report their oversight activities within ten days following a conference, and amend Ms. Dawson’s 2023 financial disclosure report.

We evaluated the Department of Homeland Security’s enterprise-wide security program for Top Secret/Sensitive Compartmented Information intelligence systems. 

The OIG inspection team assessed whether the Superintendent of Documents (SuDoc) is meeting the intent of 44 United States Code (U.S.C.) Section 1909 to “make firsthand investigation of conditions for which need is indicated” with the Public Access Assessments (PAA) of the Federal Depository Libraries (FDL).

VA medical facilities use automated dispensing cabinets to help manage medication inventory and allow clinical staff to dispense medications to patients near the point of care. The OIG conducted this national review to evaluate whether controls at VHA medical facilities ensure accountability over high-risk medications when clinical staff remove them from these cabinets using generic information, such as codes or nonpatient information.

The OIG estimated that in fiscal year 2024, VA medical facilities could not fully account for 46 percent of medications removed with generic information from cabinet A (one of two types of cabinets reviewed, called A and B in the report). Facilities had the most issues tracing propofol to specific patients. Cabinet B transactions could not be projected due to data limitations, but these transactions may also be at risk of not being traceable to a patient. These issues occurred because medical facilities’ standard operating procedures and local policies did not address monitoring of medication removals from cabinets using generic information. Some staff reported using generic information out of convenience or to be more efficient.

The OIG reviewed 40 transactions in which staff removed controlled substances using generic information and found one instance in which a facility could not trace a controlled substance to a specific patient. VHA policy does not prohibit using cabinets to store controlled substances, but it does require facilities to maintain full accountability over them through an electronic record that tracks the medication’s removal from a cabinet to its final dispensation. Removing medications without using a patient’s name increases the risk of drug diversion, so this practice should be closely monitored.

VHA concurred with the OIG’s three recommendations to enhance local guidance on, compliance with, and monitoring of these transactions.