Federal Reports

The Medicare hospice benefit allows providers to claim Medicare reimbursement for hospice services provided to individuals with a life expectancy of 6 months or less who have elected hospice care. Previous OIG audits and evaluations found that Medicare inappropriately paid for hospice services that did not meet certain Medicare requirements.

The Federal Emergency Management Agency (FEMA) has not prioritized compliance with the Disaster Mitigation Act of 2000 (DMA 2000). According to FEMA officials, the agency has instead focused on immediate needs of disaster operations and other high- profile initiatives necessary to carry out its mission. As such, FEMA has not published regulations and related policies as required by the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) to reduce repetitive damages to facilities, including the Nation’s roads and bridges. We made four recommendations to FEMA, including that FEMA should prioritize the DMA 2000 by addressing the unresolved implementation issues and publishing a regulation as required.

We found that SBA established its May 2020 COVID-19 Reconstitution Plan in accordance with applicable federal guidance. We identified issues with the implementation of the reconstitution plan that should be addressed to help the agency safeguard its employees from contracting and spreading COVID-19 in the workplace.We found the agency did not follow occupancy procedures for advancing or reverting phases at its Washington, DC headquarters. SBA also did not implement exposure tracking protocols to ensure it consistently traced COVID-19 cases. We found the agency did not consistently notify its staff of presumed or confirmed COVID-19 cases in the sampling we analyzed. SBA did not consistently contact potentially exposed personnel and ensure employees completed 14-day quarantine periods.SBA replaced the reconstitution plan with its new COVID-19 Workplace Safety Plan in February 2021. We made one recommendation for SBA to enforce the requirements of its new workplace safety plan by consistently applying procedures for occupancy and exposure tracking and to accurately record and maintain supporting documentation for all reported COVID-19 cases. SBA management agreed with our recommendation and planned actions resolve the recommendation.

An Electronic Technician based in Boston resigned from the company on July 12, 2021, prior to his disciplinary hearing. From March 30, 2021, through April 30, 2021, the former employee violated company policies by fraudulently claiming and accepting payment for over 62 hours of straight time and overtime hours that he did not work or was not authorized to work, for which he received over $2,825 in compensation. When we interviewed the employee, he initially lied about his actions but eventually admitted that he did not work all of the hours he claimed. The technician is not eligible for rehire.

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 Boise VA Medical Center and five outpatient clinics in Idaho and Oregon. 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; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.At the time of the OIG’s virtual review, the executive leaders had worked together for over three months. Employee survey results for selected leadership questions were similar to or better than the VHA average. Patient experience survey results were higher than VHA averages, and patients appeared satisfied with their care. The OIG’s review of accreditation findings, sentinel events, and large-scale disclosures did not identify any substantial organizational risk factors. During the institutional disclosures review, the OIG identified surgical complications in two patients that appeared to meet peer review criteria but were not reviewed. The executive leaders were generally knowledgeable, within their tenure and scope of responsibilities, about VHA data and/or medical center-level factors contributing to Strategic Analytics for Improvement and Learning measures.The OIG issued 10 recommendations for improvement in six areas:(1) Medical Staff Privileging• Provider exit review forms(2) Medication Management• Pain management committee processes(3) Mental Health• Suicide prevention outreach activities• Suicide prevention training(4) Care Coordination• Life-sustaining treatment decision progress notes(5) Women’s Health• Gynecologic care coverage• Designated women’s health primary care providers• Women veterans health committee meeting attendance• Women veterans program manager duties(6) High-Risk Processes• Standard operating procedures

What We Looked AtThrough its Logistics Center, the Federal Aviation Administration (FAA) maintains, repairs, and overhauls equipment for the National Airspace System (NAS). The Logistics Center is FAA’s only centralized distribution center for NAS inventory, valued at $735 million. Each year, it ships and receives approximately 200,000 parts to FAA field offices and other domestic and international customers. Previous reviews have found that FAA did not have sufficient controls in place to track and manage its inventory. Accordingly, we initiated this audit with the following objective: to determine if FAA has effective oversight controls for managing the NAS inventory, including controls to appropriately account for excess, obsolete, or unserviceable (EOU) items. What We FoundFAA lacks sufficient oversight controls for managing its NAS inventory and continues to maintain excessive quantities of old and unserviceable parts. In part, this is because FAA lost the automatic functionality for monitoring excess inventory levels after it transitioned to a new inventory management system. The transition to the new system also impacted FAA’s ability to track EOU inventory to final disposition and monitor exchange and repair (E&R) parts shipped to and from the field. Furthermore, FAA must manually recalculate inventory values for most E&R parts and faces about $1 million in quantity discrepancies. The lack of sufficient controls limits FAA’s ability to accurately report its inventory values and determine the stock levels it needs to support NAS systems. Our RecommendationsWe made seven recommendations to improve FAA’s ability to manage and provide oversight for the NAS inventory. FAA concurred with recommendations 1–4, 6, and 7. Thus, we consider these recommendations resolved but open pending an OIG review and FAA’s completion of planned actions. FAA partially concurred with recommendation 5 and provided an alternative action but did not describe the course of action it will take if parts are never returned or the impact of unreturned parts on its financial statements. Therefore, we consider recommendation 5 open and unresolved. We request that the Agency reconsider its position on this recommendation and provide us with its revised response within 30 days of the date of this report in accordance with DOT Order 8000.1C.

This report of investigation pertains to the actions of former EPA Chief of Staff Ryan Jackson and former Senior Advisor to the Region 9 Administrator Charles Munoz.

Why OIG Did This AuditThe Medicare hospice benefit allows providers to claim Medicare reimbursement for hospice services provided to individuals with a life expectancy of 6 months or less who have elected hospice care. Previous OIG audits and evaluations found that Medicare inappropriately paid for hospice services that did not meet certain Medicare requirements.How OIG Did This AuditOur audit covered 6,142 claims for which Mission (located in San Mateo, California) received Medicare reimbursement of about $37 million for hospice services provided from October 1, 2015, through September 30, 2017. We reviewed a random sample of 100 claims. We evaluated compliance with selected Medicare billing requirements and submitted these sampled claims and the associated medical records to an independent medical review contractor to determine whether the services met coverage, medical necessity, and coding requirements.

A Clerk based in Bear, Delaware, was terminated on July 8, 2021, for failing to report his December 2020 arrest for drug-related charges. Company policy requires employees to notify the company as soon as practicable after an arrest, or within 48 hours after being released from incarceration. The employee’s disclosure occurred nearly six months later, and only after he was formally asked about the arrest during the course of our investigation.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that Community Care consults were completed in June 2018 without scanning and attaching available clinical results to patients’ Veterans Health Administration (VHA) electronic health records (EHR). By completing these consults, view alerts were triggered but consult results were not available for review by ordering providers at the New Mexico VA Health Care System (facility). Additionally, it was alleged that Veterans Integrated Service Network 22 and facility leaders were aware of this practice and did not act..The OIG substantiated that in June 2018, Community Care nurses were completing consults without scanning and attaching clinical documentation to patients’ EHRs. Providers who received incorrect view alerts developed work-arounds to obtain information necessary to care for patients, and the OIG did not identify adverse clinical outcomes associated with the false view alerts for the patients reviewed.The OIG determined that Community Care nurses lacked a comprehensive orientation and training program. The Chief of Community Care did not verify adherence to consult-related VHA requirements or conduct regular reviews and improvements for departmental performance deficiencies. Additionally, Community Care performance monitoring addressed consult processes prior to patients receiving care but did not address the consult completion process or identify non-compliance with VHA policy prior to 2019.The OIG made five recommendations to the Facility Director related to the Community Care consult completion process, nursing competencies and training, Consult and Access Management Steering Committee oversight and monitoring, facility leaders’ oversight, and Community Care organizational structure and leaders’ expertise.

The OIG examined whether VA medical centers have adequate controls for, and provide sufficient oversight of, payments to affiliated nonprofit corporations. Under Intergovernmental Personnel Act agreements, VA reimburses nonprofit corporations for all or part of the salaries and associated costs for employees working on mutually beneficial research, education, and training activities.The OIG previously evaluated complaints involving nonprofit corporations affiliated with five VA medical centers. For this audit, the team added two medical centers in Albuquerque, New Mexico, and Palo Alto, California.The OIG estimated that the Albuquerque and Palo Alto medical centers made about $17.9 million in improper payments to affiliated nonprofit corporations. The reason for improper payments was the same for all seven VA medical centers reviewed. Specifically, procedures for approving invoices did not satisfy VA policy requirements because they did not require verification that the services were provided. The audit team also noted an absence of required periodic reviews by VA supervisors of approved invoices at all seven medical centers. Furthermore, triennial reviews by VA’s Nonprofit Program Office did not identify that the lack of evidence that services were provided was a problem.The OIG made three national recommendations. These included recommending that the assistant under secretary for health for discovery, education and affiliate networks establish procedures to ensure that (1) designated medical center staff verify that services invoiced by affiliated nonprofit corporations were provided before approving payment, and (2) Research and Development Budget Office supervisors conduct periodic reviews of invoices from VA affiliated nonprofit corporations that staff authorized for payment. The OIG also recommended that (3) the program office director add a step to the triennial review procedures to verify that nonprofits include evidence of providing services when they submit invoices to VA.

The OIG conducted an inspection to assess training for VA’s transition to a new electronic health record (EHR) at the Mann-Grandstaff VA Medical Center (facility) in Spokane, Washington. The OIG identified deficiencies related to training content and delivery; the VA Office of Electronic Health Record Modernization’s (VA OEHRM’s) attempt to evaluate training; the contractor’s work on training; and concerns with governance. The OIG observed that facility staff demonstrated a commitment to the EHR transition while prioritizing patient care during a global pandemic.The OIG identified training gaps and factors that may have negatively affected end users’ ability to use the new EHR: insufficient time for training; limitations with the training domain; challenges with user role assignments; and gaps in training support.Facility leaders and staff identified having insufficient time to cover training and that balancing training with duties was challenging. In addition, the user role assignment process resulted in inaccurate assignments that led schedulers to place users in incorrect training. Moreover, VA OEHRM completed assessments of the contractor’s work on training and identified deficits in meeting deadlines, staffing, management, and quality.The OIG determined the VA OEHRM training plan did not include an actionable evaluation of training and VA OEHRM withheld and altered evaluation training data. Further, evidence was not found in the current governance structure that the Veterans Health Administration had a defined role in participating in EHR modernization decision-making or oversight activities.The OIG made eight recommendations to the Deputy Secretary related to training content and delivery, contractor performance, training evaluation, and EHR governance. The OIG made three recommendations to the Under Secretary for Health related to optimizing workflows, tracking EHR patient complaints, and assessment of employee morale.

The Veterans Benefits Administration (VBA) oversees the disability compensation program, providing veterans with monthly payments because of disabilities that occurred during or were aggravated by their military service. VBA’s Office of Field Operations is responsible for ensuring these benefits are provided effectively and efficiently. Sometimes evidence is received that requires decreasing or discontinuing the benefits, called proposals to reduce benefits. Veterans are given time to challenge any proposed action while their benefits continue unchanged. Lengthy delays can waste taxpayer dollars in excessive payments that cannot be recouped.The VA Office of Inspector General (OIG) examined whether the Office of Field Operations managed proposals to reduce benefits by minimizing processing delays and excessive payments. The OIG estimated about 88 percent of claims completed during the review period involved processing delays.The delays occurred because the Office of Field Operations workload distribution strategy prioritized claims involving the granting of benefits. The OIG acknowledges VBA’s goal to ensure these claims are given priority over those that reduce or remove benefits. However, the proposed reductions cannot be allowed to increase in a way that results in excessive payments that could be directed to other eligible beneficiaries or allowable uses.If the Office of Field Operations does not develop an effective strategy to manage the workload, delays and excessive payments will continue, resulting in an estimated $232 million in excessive payments over the next two years. Further, delays may cause unnecessary stress for veterans waiting for final decisions.VBA concurred with OIG recommendations to implement a workload management strategy to distribute and process proposals to reduce benefits that minimizes delays and excessive payments, along with a formal procedure to routinely monitor that strategy. VBA requested closure of the recommendations given changes made since the review, but the OIG will monitor implementation to ensure successful completion.

The Office of the Inspector General conducted a review of the Sequoyah Nuclear Plant Chemistry/Environmental (SQN Chemistry) organization to identify factors that could impact SQN Chemistry’s organizational effectiveness. During the course of our evaluation, we identified behaviors that had a positive impact on SQN Chemistry. These included relationships with most management. However, we also identified behavioral risks related to accountability, relationships within and outside Chemistry, low morale, and ethics. In addition, we identified risks to operations that have hindered SQN Chemistry’s effectiveness. These risks were related to the physical work environment, monitoring effluents and collecting required samples, and inaccurate sample documentation.

Due to an increase in transactions regarding real estate, we performed an evaluation to assess the Tennessee Valley Authority’s (TVA) development and implementation of its strategic real estate plan. However, TVA does not formally have a strategic real estate plan; therefore, we reviewed the goals and objectives of the Strategic Real Estate and Governance (SREG) organization to determine if they were being achieved.We determined SREG has met, or was in the process of meeting, their stated goals and objectives. For example, SREG has (1) improved the condition, safety, and utilization of TVA’s real estate assets and (2) been working to eliminate noncore and underutilized buildings through regional consolidations. However, we identified several areas for improvement that could enable SREG to more effectively accomplish their mission of helping TVA manage real estate assets and align the portfolio with business need. Specifically, (1) SREG does not have an accurate and comprehensive list of all real property, (2) SREG is not always included in, or knowledgeable of, key business decisions that impact real estate, and (3) TVA does not have a centralized real estate function.

The Federal Emergency Management Agency’s (FEMA) Intergovernmental Service Agreement (IGSA) with the Texas General Land Office (TxGLO) was appropriate to ensure direct housing assistance program compliance with applicable laws and regulations. However, FEMA initiated the IGSA without first developing the processes and controls TxGLO needed to administer the program. As a result, FEMA and the State had to develop and finalize implementation guidelines after signing the IGSA, delaying TxGLO’s disaster response. In addition, FEMA disaster personnel had to prepare the necessary guidance, toolkits, and training resources while simultaneously responding to Hurricane Harvey. Also, FEMA used workarounds and TxGLO set up a separate system, creating additional operational challenges and inefficiencies. We made three recommendations to improve future state administered direct housing assistance efforts. FEMA concurred with all three recommendations

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DOJ Press Release: Disbarred Attorney Pleads Guilty To Securities Fraud In Connection With Fraudulent Opinion Letter Scheme

Without clear and enforceable limitations in synthetic-minor-source permits, facilities may emit excess pollution that would otherwise subject them to the more stringent requirements of the Clean Air Act major-source permitting programs.

Federal RequirementsPhysicians who bill for TCM services are restricted from billing for restricted overlapping care management services (77 Fed. Reg. 68985 and 68990 (Nov. 16, 2012)). Therefore, these overlapping care management services may not be billed for services provided during the same 30-day TCM service period for the same beneficiary.According to CMS officials, in these instances the first claim submitted should be paid and the second claim submitted should be denied.Physicians who bill for TCM services are restricted from billing for restricted overlapping care management services (77 Fed. Reg. 68985 and 68990 (Nov. 16, 2012)). Therefore, these restricted overlapping care management services may not be billed for services provided during the same 30-day TCM service period for the same beneficiary.According to CMS officials, in these instances the first claim submitted should be paid and the second claim submitted should be denied.

BACKGROUNDMedicaid Health Home ServicesThe Medicaid program provides medical assistance to low-income individuals and individuals with disabilities. The Federal and State Governments jointly fund and administer the Medicaid program. At the Federal level, the Centers for Medicare & Medicaid Services (CMS) administers the program. Each State administers its Medicaid program in accordance with a CMS-approved State plan. In New York, the New York State Department of Health (State agency) administers the Medicaid program.Effective January 2011, section 1945 of the Social Security Act (the Act) was amended to include an option for States to establish a health home program through a Medicaid State plan amendment (SPA) approved by CMS. Under a SPA, States can establish a health home program through a care management service model in which all parties involved in a beneficiary’s care communicate with one another so that medical, behavioral health, and social needs are addressed in a comprehensive manner. While States have flexibility to define the core health home services, they must provide all core services required in the Act. Specifically, the Act requires that health home services include comprehensive care management, care coordination, health promotion, comprehensive transitional care/follow-up, patient and family support, and referral to community and social support services. Beneficiaries enrolled in a health home program receive services through provider networks, health plans, and community-based organizations.New York’s Medicaid Health Home ProgramNew York operates a Medicaid health home program which provides comprehensive care management for beneficiaries with at least two chronic conditions or a single qualifying condition (e.g., serious mental illness). Health home providers directly provide, or contract for the provision of, health home services to eligible beneficiaries. Core health home services provided include engaging and retaining beneficiaries enrolled in the program, coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating beneficiaries’ needs. New York relies on its health home providers to locate and enroll potentially eligible beneficiaries identified by the State agency or through community-based referrals (case-finding). Beneficiaries enrolled with a health home provider are assigned a dedicated care manager to assist them with obtaining medical, behavioral, and social services (referred to by the State agency as active care management). New York’s health home program provides for a per member per month (PMPM) payment for beneficiaries in case-finding or active care management status.The State agency is primarily responsible for monitoring and overseeing the health home program and works with its interagency partners to monitor the program and review providers’ performance.The State agency claimed Medicaid reimbursement totaling $341,936,568 ($193,238,148 Federal share) for payments made to health home providers for services provided to beneficiaries diagnosed with serious mental illness and/or substance use disorder (SUD) during the period January 2016 through December 2018 (audit period).OBJECTIVEOur objective was to determine whether the State agency’s claims for Federal Medicaid reimbursement for payments made to health home providers on behalf of beneficiaries diagnosed with serious mental illness and/or SUD complied with Federal and State requirements.

The Electronic Health Record Modernization program manages VA’s transition to a new electronic health record system interoperable with the Department of Defense’s system, allowing care providers to access more comprehensive medical histories for the nine million-plus veterans enrolled in VA health care.The VA Office of Inspector General (OIG) conducted this audit because of the importance of the modernization program and its extensive costs. The audit assesses whether the Office of Electronic Health Record Modernization (OEHRM) estimated information technology (IT) infrastructure upgrade costs in accordance with VA standards and Government Accountability Office guidance. The OIG also examined whether OEHRM reported to Congress all costs needed to support the program, including future technology refreshment. This is the second OIG report this year examining VA’s development and reporting of cost estimates for infrastructure upgrades needed to support the program (See VA OIG, Deficiencies in Reporting Reliable Physical Infrastructure Cost Estimates for the Electronic Health Record Modernization Program, Report No. 20-03178-116, May 25, 2021).In this report, the OIG found weaknesses in how OEHRM developed and reported cost estimates. The two $4.3 billion infrastructure upgrade estimates reported to Congress were not reliable and, because of incomplete documentation, determining the accuracy of the estimates was not possible. The OIG also found VA did not report to Congress other IT upgrade costs of about $2.5 billion because OEHRM did not include costs other VA agencies would bear. OEHRM also did not update the cost estimates it provided to Congress.The OIG made six recommendations to help VA ensure an independent cost estimate is performed, reassess and refine the estimate to comply with standards, develop procedures consistent with guidance, disclose to Congress all costs for all IT infrastructure upgrades and updates, and formalize agreements with OIT and VHA to identify expected funding contributions from each entity.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 19 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 19 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of information given the quickly changing landscape as infection rates and demands on facilities continually shift. Findings of inspected medical facilities are grouped by VISN, which are regional offices that provide oversight of medical centers in their area.This report, the second in a series, describes findings on COVID-19 practices from healthcare inspections performed within VISN 19 during the weeks of November 30 and December 7, 2020. It also provides a more recent snapshot of the pandemic’s demands on these facilities’ operations based on data compiled as of April 2021. Interviews and survey results provide additional context on lessons learned and perceptions of both preparedness and response. This report also provides data that illustrates the tremendous COVID-19-related demands on VA healthcare services. It describes leader and staff experiences, assessments, shared sentiments, and best practices to help improve operations and clinical care during public health crises.At the time of the inspections, the Veterans Health Administration and the VISN were experiencing the highest number of cases since the beginning of the pandemic and had valuable information to share about their experiences.

OIG data analytics identified this site as having large retail floor stamp inventory count shortages and one overage from October 1, 2019 through April 30, 2021. Retail associates who work at window services are not assigned a stamp stock inventory and instead work from a shared retail floor stamp inventory. The objective of this audit was to determine whether the James Brown Jr. Station properly accounted for stamps, money orders, and cash.

The Postal Service uses a vast network of systems to collect, process, transport, and deliver nearly half of the world’s mail. The majority of these systems are classified as business applications because they support essential business functions, such as mail processing and delivery. To improve business operations and reduce cyber risk, the Postal Service invests in new and innovative applications and retires those that are outdated and no longer supported. Our objective was to assess the effectiveness of the Postal Service’s business application retirement process.

The Office of the Inspector General conducted a review of the John Sevier Combined Cycle (JSCC) Plant to identify factors that could impact JSCC’s organizational effectiveness. During the course of our evaluation, we identified behaviors that had a positive impact on JSCC. These included positive relationships between team members and management; however, we also identified minimal behavioral risks associated with communication and accountability. In addition, we identified minimal risks to operations that, if unaddressed, could hinder JSCC’s effectiveness. These were related to resource needs, such as problems obtaining parts and materials needed to perform jobs, as well as a desire for additional training, including instrument mechanic and instrumentation training.

In reviewing 16 contract files, we found files that did not have relevant Federal tax information, were missing information on the contractor’s past performance evaluations, and contained incomplete and inconsistent documentation. We attribute these deficiencies to FEMA not providing guidance on procedures for implementing Federal regulations to contracting personnel, and the Department of Homeland Security removing guidance from its acquisition manual that is used by component personnel. As a result of inadequate guidance, FEMA personnel awarded contracts without making fully informed determinations as to whether prospective contractors could meet contract demands. If contractors cannot meet demands, FEMA may have to cancel contracts it has awarded, which has happened in the past and continues. In fact, between March and May 2020, FEMA awarded and canceled at least 22 contracts, valued at $184 million, for crucial supplies in response to the national COVID-19 pandemic. By awarding contracts without ensuring prospective contractors can meet contract demands, FEMA will continue wasting taxpayer dollars and future critical disaster and pandemic assistance will continue to be delayed. We made one recommendation that, when implemented, should help strengthen FEMA’s responsibility determination process. The Department concurred with our recommendation.

Henry Abdelnoor, a former Lead Services Attendant based in New York, was sentenced in the Superior Court of New Jersey, Burlington County, on July 7, 2021, to three years of probation for stalking. The criminal charge resulted from Abdelnoor’s conduct prior to a company disciplinary hearing for posting inappropriate comments on Facebook. Prior to the hearing, Abdelnoor attempted to influence a victim’s complaint against him by allegedly offering the victim a $5,000 payment in exchange for recanting her statement in court. Abdelnoor previously pleaded guilty to the criminal charge on May 26, 2021. He resigned from the company on March 4, 2021, and is ineligible for rehire.

What We Looked AtIn response to a request from the Maritime Administration (MARAD), the National Academy of Public Administration (NAPA) reviewed MARAD’s core functions, including its role within the Department of Transportation and its contributions to the Nation. NAPA’s 2017 report included 27 recommendations to address weaknesses it identified in MARAD’s ability to articulate and meet its mission. The National Defense Authorization Act for Fiscal Year 2020 directed our office to audit MARAD’s actions to address 16 of NAPA’s 27 recommendations—related to the Agency’s program alignment, training mission, and other issues. Accordingly, the objective of this audit was to assess MARAD’s actions to address the 16 recommendations from NAPA’s 2017 report specified by Congress. What We FoundMARAD took action on 15 of the 16 recommendations we reviewed. It completed 5 of 10 recommendations related to overarching issues impacting its effectiveness, and 2 of 6 recommendations that focused on its ability to provide adequate qualified merchant mariners to meet commercial and national security needs. Nine recommendations had not been completed at the time of our audit. MARAD partially completed eight and decided not to take action on the ninth—determining that the costs outweighed the benefits. Five recommendations were partially completed because they were dependent on coordination with MARAD’s stakeholders. The other three were partially completed for a variety of reasons, including MARAD’s need to finalize policies and procedures. MARAD has indicated that it plans to take action on all of the partially completed recommendations. However, the Agency lacks updated milestones for completion or an ongoing process for tracking implementation that will place it in a better position to fulfill its mission and meet the Nation’s commercial and security needs. Our RecommendationsWe made two recommendations to facilitate MARAD’s further progress in addressing the NAPA recommendations. MARAD concurred with both recommendations and proposed appropriate actions and completion dates. Accordingly, we consider both recommendations as resolved but open pending completion of the planned actions.

For our final report on the evaluation of the United States Patent and Trademark Office’s (USPTO’s) Patent Term Adjustment (PTA) and Patent Term Extension (PTE) processes, our objectives were to determine whether USPTO (1) calculates and awards PTA and PTE in compliance with relevant statutes, regulations, and case law; (2) has adequate internal controls to ensure the proper calculation and award of PTA and PTE; and (3) uses valid and reliable data to calculate PTA and PTE.We contracted with The MITRE Corporation (MITRE)—an independent firm—to perform this evaluation. Our office oversaw the progress of this evaluation to ensure that MITRE performed the evaluation in accordance with the Council of the Inspectors General on Integrity and Efficiency’s Quality Standards for Inspection and Evaluation (December 2020) and contract terms. However, MITRE is solely responsible for the attached report and conclusions expressed in it.

The VA Office of Inspector General (OIG) conducted this review to assess the merits of an allegation made to its hotline regarding misuse of a veteran’s funds. The daughter of a now-deceased veteran for whom no VA fiduciary was appointed alleged that staff of a state veterans home in California moved her father to a memory care unit without a diagnosis of impaired memory and took control of his funds. Although the veteran was transferred to the memory care unit, the OIG did not substantiate that staff moved him there without a diagnosis of impaired memory and took control of his funds. The Veterans Benefits Administration (VBA) electronic claims file contained a statement signed by a nurse practitioner at the home attesting to his cognitive decline, and the veteran’s death certificate listed the cause of death as cardiorespiratory arrest, progressive debility and decline, and cognitive decline.Concerning his finances, documentation revealed it was not the home but the state of California that took control of the veteran’s funds. The OIG found that neither a bank statement nor the direct deposit form submitted to VA listed the state veterans home as a joint account holder. A representative from the California Department of Veterans Affairs confirmed that the veteran’s funds were frozen to recover unreimbursed care costs. According to California law, the state has the authority to recover any unreimbursed costs of care from the personal property assets of veterans who die while residing in a state veterans home.The OIG made no recommendations but determined VBA had not finalized a decision regarding the veteran’s ability to manage his benefits payments, which might have led VA to appoint a fiduciary. The OIG addressed this in a separate management advisory memorandum to VA.

OIG is required by the Federal Information Security Management Act to assess SBA’s information security program every year. In FY 2020, SBA had an unprecedented volume of loan and grant applications because of the Coronavirus Aid, Relief, and Economic Security (CARES) Act and other related pandemic legislation. As a result, the agency experienced new information security challenges. We tested a subset of systems in eight areas, called “domains,” and evaluated them using guidance for FISMA metrics. Inspectors General are required to assess the effectiveness of information security programs on a maturity model spectrum. We rated SBA’s overall program of information security as ”not effective” because SBA only achieved a maturity level rating of “managed and measurable” in one of the eight domains. Based on tests of the eight information systems, we determined the results of each domain as follows:1. Risk Management — Defined2. Configuration Management—Defined3. Identity and Access Management — Consistently Implemented4. Data Protection and Privacy — Consistently Implemented5. Security Training — Defined6. Information Security Continuous Monitoring — Defined7. Incident Response — Managed and Measurable8. Contingency Planning — Consistently Implemented. We made 10 recommendations in five of the domains: three recommendations in risk management, three recommendations for configuration management, two for identity and access management, one recommendation for security training, and one for information security continuous monitoring. SBA management agreed with the recommendations in this report.

The Office of the Inspector General (OIG) conducted an inspection of GPO’s Suspension and Debarment Program to understand its overall process, associated timelines, and evaluate the effectiveness of the dissemination of debarments inside and outside of GPO.

The VA Office of Inspector General (OIG) examined whether Veterans Health Administration (VHA) medical facilities managed time and attendance for part-time physicians on adjustable work schedules to ensure salary payments were accurate.Part-time physicians on adjustable work schedules sign agreements estimating the number of hours they will work. They are paid according to that figure, up to a maximum of 1,820 hours a year, even if they work more or fewer hours. The physicians track the number of hours actually worked in the time and attendance system. At the end of the agreement period, payroll personnel reconcile the physicians’ salary payments against the hours worked, reimbursing for underpayments and billing for overpayments.Based on a review of 134 such agreements ending in 2019, the OIG found VHA medical facilities did not adequately manage time and attendance to ensure physicians were paid correctly for an estimated 44 percent of agreements. This occurred because key management controls were missing or not working. Officials did not make certain that medical facilities complied with policies and procedures.Consequently, the OIG estimated VHA medical facilities had about $8.3 million in questioned costs that year, and an additional $8.3 million in 2020. VHA medical facilities also may have violated the prohibition against voluntary services, and potentially the Antideficiency Act, by not correcting underpayments or by having physicians working above the 1,820-hour cap because their agreements were not properly reconciled.The OIG made nine recommendations to strengthen management controls, including completing overdue reconciliations, correcting inaccurate payments, and determining whether Antideficiency Act violations occurred. Recommendations also included ensuring time and attendance records are validated and certified, physicians do not significantly deviate from their agreements or work more than 1,820 hours in a service year, and reconciliations and associated payment corrections are promptly completed.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate a primary care provider’s completion of electronic health record (EHR) documentation within the facility’s required time frame and accumulation of over 4,000 view alerts (EHR notifications) that may have resulted in patients’ adverse clinical outcomes. Also reviewed were actions taken by facility leaders to address the provider’s EHR documentation deficiencies.The OIG’s review of 220 identified patients’ care did not find adverse clinical outcomes related to the provider’s delinquent documentation. The OIG was unable to determine if patients experienced adverse clinical outcomes from the provider accumulating 4,000 view alerts, because the view alerts were addressed prior to the OIG inspection. Once addressed, view alerts are no longer active or viewable. Facility leaders reported finding no adverse clinical outcomes resulting from these view alerts.Facility leaders implemented actions to address the provider’s documentation deficiencies and monitored the provider for sustainable compliance with documentation requirements. The provider no longer treats patients at the facility.High numbers of accumulated view alerts were not isolated to the provider. However, facility leaders implemented strategies to reduce the number, and facility data showed a reduction of accumulated view alerts. Facility leaders need to continue to develop and implement strategies to manage and evaluate the effectiveness of view alerts and assess the need for retrospective reviews of patient care related to accumulated view alerts.During the inspection, the OIG also found that Health Information Management staff were not monitoring EHRs for patient care episodes without associated progress notes and facility policy did not define the time frame for providers to respond to view alerts as required by the Veterans Health Administration.The OIG made three recommendations related to providers’ view alert time frames and monitoring EHRs and view alerts.

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) 10: VA Healthcare System Serving Ohio, Indiana and Michigan in Cincinnati, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this virtual site visit during concurrent reviews of VISN 10 facilities.Executive leaders had worked as a team for three months at the time of the OIG’s virtual site visit. Employee satisfaction survey score were higher than Veterans Health Administration (VHA) averages. Patient experience survey scores were similar to or higher than VHA averages. VISN leaders had an opportunity to reduce wait times and clinical vacancies.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 seven recommendations for improvement in three areas:(1) Medical Staff Credentialing• Documented review of physician credentialing files prior to VA appointment(2) Women’s Health• Appointment of a VISN lead women veterans program manager• Quarterly program updates to executive leaders• Annual site visits at each facility(3) High-Risk Processes• VISN-led facility reusable medical equipment inspection results• Electronic posting of inspection results• VISN oversight of facility corrective action plan development and action item tracking

We did not substantiate allegations that the National Park Service improperly hired a senior political employee.

During research we found the 1915(c) Community Integration and Habilitation Waiver (CIH Waiver) services that Indiana reported on the Form CMS-64 accounted for just over $1.1 billion in Medicaid expenditures during Federal fiscal years (FFYs) 2015 and 2016. These expenditures represented approximately 5.9 percent of the total Medicaid expenditures reported on the Form CMS-64 during this period. We decided to perform this audit of the CIH Waiver services because of the significant dollar expenditures. Our objective was to determine whether Indiana ensured that CIH Waiver services at 12 selected providers were provided in accordance with Federal, State, and waiver requirements.

This audit is part of a series of hospital compliance audits. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2018, Medicare paid hospitals $179 billion, which represents 47 percent of all fee-for-service payments for the year.Our objective was to determine whether Lake Hospital System (the Hospital) complied with Medicare requirements for billing inpatient and outpatient services on selected types of claims.

OIG evaluated FSA's and the State of Florida's delivery of the CRBG Program.

The VA Office of Inspector General (OIG) conducted an inspection at the request of Chairman Mark Takano, House Committee on Veterans’ Affairs, to assess allegations that facility staff failed to adequately evaluate and treat Traumatic Brain Injury (TBI) for patients who served in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) at the Southeast Louisiana Health Care System in New Orleans.The OIG did not substantiate the allegations that the facility polytrauma program failed to adequately evaluate and treat TBI for patients who served in OEF/OIF/OND.The OIG reviewed data from the Veterans Health Administration (VHA) Support Service Center and found the facility screening rate generally met or exceeded VHA’s national benchmark.The OIG conducted an independent electronic health record (EHR) review to determine if patients who had a positive initial TBI screen conducted at the facility from October 1, 2017, through September 30, 2020, received a Comprehensive Traumatic Brain Injury Evaluation (CTBIE), and if the CTBIE was completed within 30 days.The OIG reviewed 327 EHRs and found 243 CTBIEs were completed, with 172 of them completed within 30 days. The OIG found scheduling challenges, primarily patient causal factors, contributed to why CTBIEs were not timely completed. Of the 243 CTBIEs completed, 181 patients were diagnosed as having a TBI.Clinical services were initiated for 162 of the 175 patients where services were indicated. The OIG found that the plans of care were thorough and found several areas in which facility staff exceeded VHA standards.The OIG did not identify adverse clinical outcomes for patients whose CTBIE was not timely completed or where clinical services were indicated but not initiated.The OIG found that facility leaders also oversaw two EHR reviews of the assessment and evaluation of facility TBI patients.The OIG made no recommendations.

OIG is pleased to announce our risk-based Biennial Audit Plan for Fiscal Years (FY) 2022–2023. The OIG Biennial Audit Plan includes eight statutorily mandated audits and eight discretionary audits of the AbilityOne Program. Throughout the 2022–2023 audit cycle, OIG will continue to focus on high-risk areas in the program and operations, as well as aspects of the Program related to the pandemic.This plan provides a detailed roadmap for independent and objective audits focused on enhancing confidence in the program, increasing economies and efficiencies, and fostering program growth, while preventing and detecting fraud, waste, and abuse.Our process to select and prioritize our planned work included assessing the top management and performance challenges, congressional interests, the results of our prior work, and key risks that Commission staff identified. OIG then used this information to inform discussions with Commission Members as well as members of the Commission’s executive leadership team about audits that will help improve Commission work and advance operations.

OIG evaluated APHIS’ controls to ensure compliance with the AWA and followed up on agency actions in response to a previous audit; OIG could not fully evaluate APHIS’ controls due to the COVID-19 pandemic.

What We Looked AtThe Federal Railroad Administration (FRA) provides the National Railroad Passenger Corporation (Amtrak) with funds appropriated by Congress--approximately $2 billion for fiscal year 2020 and over $3.7 billion in supplemental appropriations for the response to the Coronavirus Disease 2019 pandemic. Congress has also authorized FRA to use a portion of the annual Amtrak appropriations for its grant administration and oversight. Given FRA's role in overseeing this large Federal investment, we initiated this audit to assess FRA's program to oversee Amtrak's use of Federal funding.What We FoundFRA has not fully adopted a grants management framework for its Amtrak oversight program. It lacks measurable goals and metrics, complete policies and procedures to assess Amtrak's adherence to requirements, and a centralized grants management system. In 2017, FRA began to develop a strategic vision and focus areas for its Amtrak agreements but has not formalized measurable goals or metrics to assess progress in meeting them. Furthermore, FRA's policies and procedures are incomplete on documenting, tracking, and taking action on Amtrak noncompliance that FRA identifies during monitoring. Finally, FRA does not fully use its centralized grant information system to document and analyze findings from its monitoring reviews of Amtrak. According to FRA officials, the program's strategic framework and policies and procedures are incomplete because FRA focused first on improving the information Amtrak provides; these improvements enhanced FRA's ability to understand Amtrak's use of Federal funding. Officials also indicated that Amtrak's unique legal status limits actions FRA can take to prompt Amtrak to remedy problems the Agency identifies and Amtrak's reporting requirements present challenges for FRA to adapt its grants management information system to help oversee Amtrak's Federal funding. These weaknesses may hinder FRA's ability to assess its program's effectiveness, improve the program, and maximize returns on investment in AmtrakRecommendationsFRA concurred with our four recommendations to help improve its oversight of Amtrak's use of Federal funding. We consider these recommendations resolved but open pending completion of planned actions.

The objectives of our inspection were to describe 1. the involvement of the U.S. Department of Education (Department) in transactions among Education Management Corporation, Dream Center Education Holdings, LLC (Dream Center), Education Principle Foundation, and Studio Enterprise Manager, LLC, and the steps the Department took to protect students and taxpayers; 2. how the Department drew down and applied surety funds from letters of credit for Education Management Corporation and Dream Center and how the Department ensured that the surety funds were used in accordance with the terms of the provisional program participation agreements and any other requirements; and 3. how the Department ensured that Dream Center complied with requirements for drawing down and disbursing Title IV of the Higher Education Act of 1965, as amended (Title IV), program funds.During and after Federal Student Aid’s (FSA) preacquisition review, the Department identified significant financial risks associated with Dream Center’s purchase of 13 postsecondary schools, including Dream Center’s loss of the financial backing of an investor who was to provide at least 50 percent of the capital for the purchase, Dream Center’s lack of experience investing in or operating schools participating in the Title IV programs, potential cash flow issues, and more than a decade of failing financial health scores for all 13 schools.

The VA Office of Inspector General (OIG) conducted this review to determine whether Veterans Health Administration (VHA) contracting officers complied with mandates to ensure contractors account for and return their personnel’s personal identity verification (PIV) cards as required, such as at the end of a contract or employment. PIV cards are federally issued credentials used by authorized individuals to gain access to federal facilities and information systems. The Federal Acquisition Regulation (FAR) establishes that it is the contracting officer’s responsibility to ensure that contractor employees return all PIV cards they are issued. Unreturned cards increase risks for unauthorized access to VA facilities and information systems.The review team examined a random sample of 46 professional service and healthcare resource contracts. None of the reviewed contracts had adequate evidence to demonstrate FAR requirements were met. VHA contracting officers’ noncompliance with PIV card requirements occurred because they were unaware of their responsibilities and the requirements. In addition, VHA did not have policies or procedures detailing supervisory oversight of contracting officers’ duties regarding PIV cards, the internal audit office did not review compliance, and there was no automated tool for continuous tracking and monitoring of PIV cards issued to contractors’ personnel.The OIG made 10 recommendations to the under secretary for health to address deficiencies related to compliance with requirements for PIV cards issued to contractors’ personnel. Recommendations include ensuring all PIV cards are returned prior to contract closeout, outlining specific supervisory responsibilities for contracting officer oversight, and periodically reviewing contract compliance. The OIG also recommended VHA assess whether the existing and planned information systems could have the functionality to allow effective and routine monitoring of contractors’ PIV cards or a new system is needed.