Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the North Florida/South Georgia Veterans Health System, which includes the Malcom Randall VA Medical Center in Gainesville and the Lake City VA Medical Center . The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the review, the assistant director position had been vacant since 2019, with the Deputy Director and the Associate Director, Lake City sharing the responsibilities. All but one of the assigned leaders had worked together for over one year. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Selected patient experience scores implied general satisfaction. However, survey results also highlighted opportunities to improve satisfaction for male and female veterans in inpatient and outpatient settings.The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued six recommendations for improvement in four areas:(1) Quality, Safety, and Value• Surgical work group attendance(2) Registered Nurse Credentialing• Primary source verification(3) Care Coordination• Receiving physician identification• Medication list transmission(4) High-Risk Processes• Staff training

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Boston Healthcare System and multiple outpatient clinics in Massachusetts. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The system’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together for over six years. Selected employee satisfaction survey responses demonstrated satisfaction with leaders and maintenance of an environment where staff felt respected and discrimination was not tolerated. Patient experience survey data indicated satisfaction with the care provided.Executive leaders were able to speak in depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance. The inspection team reviewed accreditation agency findings and did not identify any substantial organizational risk factors. However, the OIG identified deficiencies with institutional disclosures of adverse events.The OIG issued eight recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Institutional disclosures(2) Quality, Safety, and Value• Peer review process(3) Mental Health• Suicide risk screening(4) Care Coordination• Patient transfer policy• Monitoring and evaluation of patient transfers• Transfer forms• Medication list transmission• Nurse-to-nurse communication

The Office of Inspector General (OIG) completed a final action verification of all three recommendations in our September 2018 interim report, Single Family Housing Guaranteed Loan Program—Liquidation Value Appraisals—Interim Report (Audit Report 04601-0001-23(1)).

Patching is the process for updating products and systems. Patches correct security and functionality problems in software and firmware. We performed an audit of the Tennessee Valley Authority’s (TVA) patching of Windows® desktops and laptops to determine if high-risk vulnerabilities on desktops and laptops were patched in accordance with TVA policy and best practices. We found (1) TVA policies and procedures aligned with best practices, (2) the majority of Windows® desktops and laptops managed by TVA’s automated patching system were patched for high-risk vulnerabilities in accordance with TVA policy, and (3) TVA had mitigated vulnerabilities for Windows® desktops and laptops that had not received updates. However, although the majority of Windows® workstations were managed by TVA’s automated patching system, we found some desktops and laptops were at potential risk of compromise.

Objective: To (1) evaluate internal controls over the accounting and reporting of administrative costs by the California Disability Determination Services (CADDS) for Fiscal Years (FY) 2017 and 2018; (2) determine whether the administrative costs claimed on the most recently submitted Form SSA-4513 were allowable and properly allocated; (3) reconcile funds drawn down with claimed costs; and (4) assess the general security controls environment.Note: 4 of 10 recommendations not published; related to sensitive IT matters.

Peer Review: System Review Report on the Securities and Exchange Commission's Office of Inspector General Audit Organization

Objective: To (1) determine whether the Social Security Administration (SSA) made payments to beneficiaries and/or representative payees who were deceased according to California Department of Public Health records and (2) identify non-beneficiaries in the State files whose death information did not appear in Agency records.

The objectives of our audit were to determine whether National Aviation Academy of Tampa Bay (1) applied and documented its use of professional judgment in accordance with sections 479A and 480 of the Higher Education Act of 1965, as amended (HEA), and (2) reported its use of professional judgment in accordance with the Application and Verification Guide. National Aviation Academy of Tampa Bay did not adequately document special circumstances for 34 of the 37 students for whom it applied professional judgment, including dependency override, for award year 2017–2018 or award year 2018–2019. Because the school did not adequately document special circumstances, its application of professional judgment, including dependency override, was not in accordance with sections 479A and 480 of the HEA. Although it did not adequately document its use of professional judgment, including dependency override, National Aviation Academy of Tampa Bay reported all instances of its use of professional judgment, including dependency override, to the Department’s Central Processing System in accordance with the Application and Verification Guide.

Judy Azar, a medical assistant based in Los Angeles, pleaded guilty in U.S. District Court, Central District of California, on September 24, 2021, to health care fraud, bank fraud, identity theft and tax fraud. Our investigation found that Azar participated in a scheme to defraud health care benefit programs by using false and fraudulent pretenses in connection with the delivery of, and payment for, health care benefits and services.Azar forged a doctor’s signature to fraudulently authorize prescription refills and then sold a portion of the filled prescriptions to interested buyers. The buyers paid Azar with checks made payable to the doctor. Azar then forged the doctor’s signature to endorse the checks, which were then deposited in bank accounts controlled by Azar. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $13,500.

The objective of our audit was to determine whether Lincoln College of Technology (Lincoln) used the Student Aid (Assistance Listing Number (ALN) 84.425E) and Institutional (ALN 84.425F) portions of its Higher Education Emergency Relief Fund (HEERF) funds for allowable and intended purposes. We also reviewed Lincoln’s cash management practices and the timeliness and quality of the data Lincoln reported on its use of HEERF funds.LESC generally used the Student Aid portion of Lincoln’s HEERF funds for allowable and intended purposes but did not always use the Institutional portion of its funds in accordance with Federal requirements. We found that LESC did not adequately document eligibility determinations for a small number of students who received emergency financial aid grants, improperly applied Institutional grant funds to credit student accounts, improperly charged expenditures that extended beyond the grant performance period, and did not follow cash management requirements.

Top Management and Performance Challenges Facing the Federal Labor Relations Authority

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Maine Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The leadership team appeared stable, with all the positions permanently assigned. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Patient experience survey results highlighted opportunities to improve female veterans’ satisfaction in inpatient and outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued eleven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Systems redesign and improvement program process• Peer review quarterly summaries• Surgical work group attendance(2) Care Coordination• Patient transfer policy• Patient transfer monitoring and evaluation• Informed consent• Transfer form completion• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Disruptive Behavior Reporting System• Staff training

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate a patient’s mental health care at the VA Portland Health Care System (facility) including care coordination, administrative actions following the patient’s death, and non-VA community care procedures. The OIG also evaluated VA Palo Alto Health Care System (VA Palo Alto) posttraumatic stress disorder residential rehabilitation treatment program (RRTP) processes.Facility staff made reasonable efforts to accommodate the patient’s treatment preferences, completed safety planning, and conducted required military sexual trauma screening and care. Facility leaders and staff did not assign a Mental Health Treatment Coordinator (MHTC) or establish a policy as required. Facility staff did not review the patient’s high risk for suicide patient record flag timely or ensure the facility’s High Risk Review Workgroup approved flag inactivation, inadequately managed the patient’s flag, and failed to assess suicide risk following the patient’s Veterans Crisis Line call.The OIG identified Veterans Health Administration (VHA) policy and suicide behavior reporting guidance inconsistencies and facility leaders did not follow VHA staff-specific guidance. Facility staff did not complete a behavioral health autopsy timely.VA Palo Alto RRTP staff did not complete the patient’s screening within VHA expectations and did not accept patient self-referrals. RRTP staff appropriately considered the patient’s service animal request. However, inconsistent with VHA policy, RRTP policy included additional admission requirements for the service animal.The OIG made two recommendations to the Under Secretary for Health related to suicide behavior and overdose report staff-specific guidance and RRTP admission decision timeframe expectations; three recommendations to the Facility Director related to MHTC policy and assignment, suicide behavior and overdose report staff-specific guidance, and behavioral health autopsy report timeliness; and two recommendations to the VA Palo Alto Director related to aligning facility RRTP procedures and assistance dog policies with VHA requirements.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Maine Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The leadership team appeared stable, with all the positions permanently assigned. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Patient experience survey results highlighted opportunities to improve female veterans’ satisfaction in inpatient and outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued eleven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Systems redesign and improvement program process• Peer review quarterly summaries• Surgical work group attendance(2) Care Coordination• Patient transfer policy• Patient transfer monitoring and evaluation• Informed consent• Transfer form completion• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Disruptive Behavior Reporting System• Staff training

To enable veterans to function at their highest level, VA provides medically prescribed prosthetic and rehabilitative items and services to eligible recipients. In fiscal year 2019, such items—artificial limbs, shoes, shoe inserts, and compression garments—accounted for about $318.8 million, or about 9 percent of prosthetic spending.The Office of Inspector General (OIG) conducted this audit to determine if Veterans Health Administration (VHA) oversight ensured medical facilities paid reasonable prices when reimbursing vendors for prosthetic and orthotic items. Previous OIG audits identified weaknesses in VHA’s oversight, which led to overpayments to vendors and missed opportunities for cost savings.The OIG found VHA’s oversight of prosthetic spending was ineffective, resulting in medical facilities sometimes reimbursing vendors at unreasonable rates; medical facilities spent about $10 million more than reasonable rates in the six-month period from October 2019 through March 2020. Furthermore, the OIG found that prosthetic spending data was unreliable—about 36,200 transactions in the National Prosthetics Patient Database from October 2019 through March 2020 contained at least one inaccurate data element, including the price paid.Unreasonable rates, along with data inaccuracies, occurred because Prosthetic and Sensory Aids Service leaders did not assume their oversight role, assess laws and regulations applicable to prosthetic spending to ensure reasonable rates, review and update oversight roles and responsibilities in policies, or establish processes and procedures to monitor the accuracy of prosthetic spending data.The OIG made four recommendations, including determining and clarifying which reimbursement practices apply to the rates medical facilities pay vendors, monitoring spending to make sure medical facilities reimburse vendors at reasonable prices, establishing a formal oversight structure to define roles and responsibilities within the prosthetic program, and requiring routine monitoring of medical facilities’ data to improve accuracy.

Objective: To (1) evaluate internal controls over the accounting and reporting of administrative costs by the Pennsylvania Bureau of Disability Determination (PA-BDD) for Fiscal Years (FY) 2017 and 2018; (2) determine whether the administrative costs claimed on the most recently submitted Form SSA-4513 were allowable and properly allocated; (3) reconcile funds drawn down with claimed costs; and (4) assess the general security controls environment.

Objective: To (1) evaluate internal controls over the accounting and reporting of administrative costs by the Kentucky Disability Determination Services (KYDDS) for Fiscal Years (FY) 2017 and 2018; (2) determine whether the administrative costs claimed on the most recently submitted Form SSA-4513 were allowable and properly allocated; (3) reconcile funds drawn down with claimed costs; and (4) assess the general security controls environment.Note: 2 of 9 recommendations not published; related to sensitive IT matters.

Our objective was to determine whether the Postal Service provided advance approval for a supplier to charge overtime hours as required.The Postal Service established its Enterprise Technology Services indefinite delivery indefinite quantity contract to increase staff to support Information Technology (IT) operations nationwide. The contract defines overtime work as hours in excess of a 40-hour work week. The supplier’s contract employees record their workhours in the Program Cost Tracking System (PCTS), a timekeeping application contract employees use to enter hours for tasks performed. IT program managers and contracting officer representatives (COR) review, validate, and approve timecards for invoice payments to the supplier in PCTS.

Our objective was to assess whether the Postal Service effectively hired bargaining employees for the peak season periods of 2019 through 2021.Peak season employees help ensure that Postal Service customers receive quality mail service and parcels on-time during the holiday season. Individuals hired during peak season are non-career bargaining unit employees who supplement existing staffing and work from November until January.

Our objective was to determine whether the Postal Service complied with applicable maximum total compensation provisions of the Postal Accountability and Enhancement Act of 2006 (PAEA) and related Postal Service policies and guidelines for calendar year (CY) 2020.

We did not substantiate allegations that a now-former DOI senior official may have violated Federal ethics laws and the Federal ethics pledge.

The objective was to determine how effectively FEMA supported and coordinated Federal efforts to distribute personal protective equipment (PPE) and ventilators in response to the COVID-19 outbreak. We determined that FEMA did not have reliable data to inform allocation decisions and ensure accurate adjudication of resource requests, it did not have a process to allocate the limited supply of PPE, and FEMA’s strategic documents did not clearly outline roles and responsibilities to lead the Federal response. We made three recommendations that FEMA improve the reliability of WebEOC, formally document the policies and procedures for allocating critical lifesaving supplies and equipment, and that FEMA work with the Secretary of Health and Human Services to clarify the agencies’ pandemic response roles and responsibilities under Stafford Act declarations. FEMA concurred with all three recommendations which remain open and resolved.

Our objective was to analyze the risk of illegal, improper, and erroneous purchases and payments made through the Department’s purchase card program.We assessed the risk of illegal, improper, and erroneous purchases made through the Department’s purchase card program as moderate-high and determined that an audit or review of the program by OIG may be warranted.

To see our report, click on the link below

We performed an audit of the Tennessee Valley Authority’s (TVA) management of privileged accounts. Our objective was to determine if TVA's management of privileged accounts is following TVA policy and best practices. A privileged user has an account that is authorized for the performance of security-related functions that ordinary users cannot perform. Privileged account management can be defined as managing and logging account and data access by privileged users.In summary, we found several controls of TVA’s privileged account management to be generally effective, including (1) an accurate inventory of privileged network device accounts, (2) appropriate segregation of duties, (3) appropriate account lifecycle management for most privileged users, and (4) monitoring of privileged accounts. However, we also found (1) improper usage of primary user accounts with privileged access, (2) one account with inappropriate privileged access, and (3) several gaps in TVA’s Standard Programs and Processes when compared to best practices.

The Agency needs to improve oversight of its approximately $25 million in annual purchase card and convenience check expenses to be better stewards of taxpayer dollars.

Our objective was to determine whether fiscal year (FY) 2020 expenditures of the Postal Service Board of Governors (Board) were properly supported, reasonable, and complied with Postal Service and Board policies and procedures.The Postal Reorganization Act of 1970, as amended, established the Board which is comprised of nine governors appointed by the president of the United States, the postmaster general, and the deputy postmaster general. While the members of the Board changed through the year, as of September 30, 2020, the Board consisted of the chairman, five governors, and the postmaster general.

The VA Office of Inspector General (OIG) conducted an inspection to assess the oversight and performance of a physician in fellowship training (subject physician) at the VA Sierra Nevada Health Care System in Reno (facility).In early 2021, Canadian authorities arrested the subject physician for the alleged murder of a patient. The subject physician participated in a University of Nevada, Reno (UNR) affiliated geriatric fellowship from fall 2018 through fall 2019, providing care to patients at the facility. The OIG initiated an inspection to review the subject physician’s patient care, the facility’s oversight of the subject physician, and assess VA leaders’ response to the reported allegations.The OIG identified 105 patients that the subject physician provided care to, 17 of whom died. The OIG reviewed the 17 deaths, finding no deficiencies in the quality of care provided by the subject physician, and no patients died from events outside the naturally expected clinical course. The OIG noted an acceptable level of patient care management by the subject physician and found no statistically significant relationship between the subject physician’s rotations and patient deaths.The facility staff and leaders, in conjunction with UNR, onboarded the subject physician per Veterans Health Administration (VHA) requirements. The subject physician’s supervision and evaluation during the fellowship met performance standards and VHA requirements.The OIG determined that facility leaders initiated an issue brief and conducted an electronic health record review of the patients the subject physician treated. However, the Veterans Integrated Service Network (VISN)-led review only included two patient deaths. Based on the criminal allegations, the OIG requested a review focused on the subject physician’s care provided prior to relevant patients’ deaths. The VISN completed the review of an additional seven patients, noting no clinical deficits in care or contribution to patient deaths.The OIG made no recommendations.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ reusable medical equipment (RME) programs. This evaluation focused on facility Sterile Processing Services (SPS) processes for reusable medical equipment related to administration, quality assurance, and staff training.This report describes RME-related findings from healthcare inspections performed at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG reviewers examined relevant documents and training records, observed reprocessing and storage areas, and interviewed key managers and staff. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses in various key RME-related processes and issued seven recommendations related to:• Standard operating procedures aligning with manufacturers’ guidelines• Annual risk analysis reporting to the VISN SPS Management Board• SPS chiefs developing, implementing, and enforcing a daily cleaning schedule for all SPS areas• Equipment storage• Completion of Level 1 training within 90 days of hire, competency assessments for RME, and monthly continuing education for SPS staff

We have performed audits in multiple States in response to a congressional request concerning deaths and abuse of residents with developmental disabilities in group homes. Federal waivers permit States to furnish an array of home and community-based services to Medicaid beneficiaries with developmental disabilities so that they may live in community settings and avoid institutionalization. The Centers for Medicare & Medicaid Services (CMS) requires States to implement a critical incident reporting system to protect the health and welfare of Medicaid beneficiaries receiving waiver services.

Objective: To (1) evaluate internal controls over the accounting and reporting of administrative costs by the Texas Disability Determination Services (TXDDS) for Fiscal Years (FY) 2018 and 2019, as well as indirect costs for FY 2017; (2) determine whether the administrative costs claimed on the most recently submitted Form SSA-4513 were allowable and properly allocated; (3) reconcile funds drawn down with claimed costs; and (4) assess the general security controls environment.Note: 1 of 9 recommendations not published; related to a sensitive IT matter.

The Transportation Security Card Program Assessment (Public Law 114-278) requires DHS to assess the effectiveness of the Transportation Security Card Program and to prepare a corrective action plan (CAP) to respond to any findings. Our objective was to determine DHS’ compliance with the public law. We determined that DHS did not fully comply with the public law. TSA and the Coast Guard prepared, and DHS submitted, a CAP to Congress in June 2020. Although the CAP identified corrective actions for one area, it did not address four issues we consider significant. We recommended that DHS, in consultation with TSA and Coast Guard, re-evaluate the assessment to determine if further corrective actions are needed or justify excluding significant issues from the CAP. DHS did not concur with the recommendation, but we consider DHS’ actions partially responsive to the recommendation. We consider the recommendation open and unresolved.

We did not substantiate the allegations that a tribal administrator misused tribal funds.

OIG evaluated OASCR’s oversight of the civil rights complaints process.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 19: VA Rocky Mountain Network in Glendale, Colorado, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The VISN’s executive leadership team had worked together for nearly six months at the time of the OIG’s review. All members of the leadership team were permanently assigned, and two members had over 30 years of VA experience. Selected survey scores related to employees’ satisfaction with the VISN executive team leaders were generally higher than VHA averages. However, the Deputy Network Director had opportunities to improve employee perceptions of leadership. Patient experience survey scores were similar to VHA averages.The OIG’s review of access metrics and clinical vacancies did not identify any substantial organizational risk factors. The executive leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. They were also knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning metrics and should continue to take actions to sustain and improve performance.The OIG issued four recommendations for improvement in three areas:(1) Quality, Safety, and Value• Peer review summary data(2) Medical Staff Credentialing• Physician credential file review(3) Women’s Health• Quarterly program updates• Staff education gaps assessments

In follow-up to the VA Office of Inspector General (OIG) report, Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas, the OIG conducted a healthcare inspection to evaluate progress in responding to pathology reading errors identified during a look-back review of cases interpreted by Dr. Robert Levy between September 2005 and October 2017. The OIG determined facility processes related to disclosure of the pathology errors and amending patients electronic health records generally met Veterans Health Administration policy requirements, but opportunities for improvement existed.Look-back reviewers categorized cases according to their disagreement with the original diagnosis and potential harm to the patient (level 0–3). Cases categorized as level 2 or level 3 diagnostic errors were referred to a Clinical Review Team to determine the impact on patient care and need for clinical and institutional disclosure. The OIG determined the facility made reasonable efforts to conduct disclosures, completing all but six of the institutional disclosures and 76.5 percent of the clinical disclosures recommended by the Clinical Review Team. The OIG noted an absence of a clearly defined process for clinical providers to alert the Clinical Review Team if later changes in a patient’s health required reconsideration of institutional disclosure.The look-back review coordinator entered amended pathology reports into the electronic health record for patients identified with level 3 diagnostic errors. However, the facility struggled with completing amended reports for patients with level 2 diagnostic errors—fewer than 5 percent of the level 2 amended reports were completed as of March 2021.The OIG made two recommendations to the Under Secretary for Health related to documentation of clinical disclosures and provider communication to the Clinical Review Team. One recommendation was made to the Facility Director related to amendment of the remaining pathology reports.

The Postal Service’s customer care phone number, 1-800-ASK-USPS, is one of the primary channels for customers to connect with the Postal Service. When customers call 1-800-ASK-USPS, their call is initially handled by an Interactive Voice Response (IVR) system. Using voice commands or keypad inputs, customers can navigate the IVR system to get information or complete tasks, such as finding the location and hours of post offices or tracking a package. Survey results suggest that customer experiences with the Postal Service’s IVR system are improving. Between FY 2019 and FY 2020, customers reported improved satisfaction with the IVR experience and more customers reported their inquiry was resolved. However, opportunities exist for continued improvement. In FY 2020, roughly one-quarter of IVR survey respondents were very dissatisfied with their IVR experience.

Mail is processed manually when its dimensions or address quality prevent it from being processed on mail processing equipment or to meet service standards when machines are at capacity.Processing mail manually is less productive (which is calculated by dividing mailpieces processed by workhours charged) and more costly than processing mail on machines, impacting overall efficiency. Specifically, the Postal Service’s automated processing is six times more productive for letters and flats and nearly four times more productive for packages than processing manually. Our objective was to assess the efficiency of the Postal Service’s manual mail processing operations.

The Office of the Inspector General conducted a review of the Transmission Field Operations, North Maintenance organization to identify factors that could impact its organizational effectiveness. During the course of our evaluation, we identified behaviors that had a positive impact on Transmission Field Operations – North Maintenance; however, we also identified needed improvements related to coworker interactions with a few employees. We also identified minimal risks to operations related to resource concerns, including inadequate staffing and equipment and/or tool needs.

We found issues in the FWS’ contract evaluation and award process and documentation related to certified cost or pricing data requirements.

We present the status of ONHIR’s grazing responsibilities and activities on Navajo Nation land in Arizona known as the New Lands.

We present the status of ONHIR’s operation of the Padres Mesa Demonstration Ranch on Navajo Nation land in Arizona known as the New Lands.

We present the status of ONHIR’s range maintenance responsibilities and activities on Navajo Nation land in Arizona known as the New Lands.

We did not substantiate allegations that the former director of a tribal credit department misappropriated funds from the tribal loan program.

We did not substantiate the allegations that an oil and gas company intentionally reduced its reported mineral sales volumes.

Rescue 21 Alaska, Coast Guard’s maritime search and rescue communication system, has experienced outages resulting from antiquated equipment in Coast Guard’s District 17. Challenges and funding shortages during system acquisition caused Coast Guard to limit the purchase of new equipment for Rescue 21 Alaska, requiring District 17 to maintain existing equipment for longer than initially planned. Alaska’s winter weather conditions and remote access to communication site locations cause lengthy repair times, further exacerbating the outage impacts. The outages have prevented Coast Guard, at times, from effectively receiving and responding to distress calls from mariners. Coast Guard has made some upgrades to the Rescue 21 Alaska system to enhance distress communication availability and reliability. Although Coast Guard plans for further upgrades, outages persist. When notifying the public about the outages, Coast Guard primarily relies on a “Local Notice to Mariners” posted on their public website. However, this limits who can receive the notices, as not all mariners go to the internet to determine outage locations. Alaska mariners shared other effective methods Coast Guard could use to improve its notifications to the public when there are known VHF distress communications outages. Adequately upgrading the communications equipment and ensuring robust attempts are made to notify the public when outages occur is essential for Coast Guard to achieve its search and rescue mission in Alaska. We made two recommendations to ensure the Coast Guard is prioritizing Rescue 21 Alaska upgrades and appropriately notifying the public of outages. Coast Guard concurred with both recommendations.

The objective was to determine the extent to which TSA has implemented requirements of the 9/11 Act and TSA Mod Act to develop strategies, programs, regulations, reports, and other initiatives to strengthen transportation security. Although TSA implemented 167 of the 251 (67 percent) requirements in both Acts, 55 of the 167 (33 percent) were not completed by the Acts’ established deadlines, and TSA did not complete the remaining 84 requirements. TSA was unable to complete 33 of these requirements because the actions relied on external stakeholders acting first or depended on conditions outside of TSA's control.

Our audit objective was to determine to what extent the Transportation Security Administration’s (TSA) acquisition of computed tomography (CT) systems addresses needed capabilities. We determined TSA acquired CT systems that did not address all needed capabilities. These issues occurred because the Department of Homeland Security did not provide adequate oversight of TSA’s acquisition of CT systems. DHS is responsible for overseeing all major acquisitions to ensure they are properly planned and executed and meet documented key performance thresholds. However, DHS allowed TSA to use an acquisition approach not recognized by DHS’ acquisition guidance. In addition, DHS allowed TSA to deploy the CT system even though it did not meet all TSA key performance parameters. DHS also did not validate TSA’s detection upgrade before TSA incorporated it into the CT system. As a result, TSA risks spending over $700 million in future appropriated funding to purchase CT systems that may never fully meet operational mission needs. We made three recommendations to improve DHS’ oversight of TSA’s CT systems acquisition. DHS concurred with all three recommendations.

FEMA does not always appropriately report and investigate employee allegations of sexual harassment and workplace sexual misconduct. For FYs 2012 to 2018, we identified 305 allegations from FEMA employees potentially related to sexual harassment and sexual misconduct such as sexual assault, unwelcome sexual advances, and inappropriate sexual comments. However, we were unable to determine whether FEMA properly handled 153 of these allegations, because it could not provide complete investigative and disciplinary files. For allegations that had complete files available, at times we were unable to determine whether FEMA conducted an investigation. Finally, we found FEMA did not document whether it investigated some sexual harassment EEO complaints as potential employee misconduct. We attribute the inconsistent investigations and incomplete files to inadequate policies, processes, and training. These shortcomings may fuel employee perceptions that FEMA is not addressing sexual harassment and sexual misconduct and is not supportive of employees reporting that type of behavior. We made five recommendations to improve FEMA’s handling of sexual harassment and misconduct allegations including establishing a comprehensive case management system; developing and implementing formal processes and procedures to appropriately address all harassment allegations; providing investigative training; and ensuring allegations are appropriately referred to DHS OIG.

The objective of this review was to determine to what extent the Department of Homeland Security has implemented COVID-19 measures for migrants at the southwest border. We reported that U.S. Customs and Border Protection (CBP) does not conduct COVID-19 testing for migrants who enter CBP custody and is not required to do so. Instead, CBP relies on local public health systems to test symptomatic individuals. According to CBP officials, as a frontline law enforcement agency, it does not have the necessary resources to conduct such testing. For migrants that are transferred or released from CBP custody into the United States, CBP coordinates with DHS, U.S. Immigration and Customs Enforcement, U.S. Department of Health and Human Services, and other Federal, state, and local partners for COVID-19 testing of migrants. In addition, although DHS generally follows guidance from the Centers for Disease Control and Prevention for COVID-19 preventative measures, the DHS’ multi-layered COVID-19 testing framework does not require CBP to conduct COVID-19 testing at CBP facilities. Further, DHS’ Chief Medical Officer does not have the authority to direct or enforce COVID-19 testing procedures.

We did not substantiate the allegations that an oil and gas company submitted false mineral production reports to ONRR.