Federal Reports

We audited costs claimed by the Rhode Island Department of Environmental Management, Division of Fish and Wildlife (Division), under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program. We conducted this audit to determine whether the Division used grant funds and State hunting and fishing license revenue for allowable fish and wildlife activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. The audit period included claims totaling $42.9 million on 34 grants that were open during the State fiscal years that ended June 30, 2017, and June 30, 2018.We determined that the State did not ensure that grant funds and State hunting and fishing license revenue were used for allowable fish and wildlife activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. We found deficiencies in internal controls resulting in our five findings of (1) insufficient controls over grant-specific data, (2) improper drawdown support, (3) inadequate real property management, (4) inadequate equipment inventory management, and (5) inaccurate license certifications.The FWS concurred with our 11 recommendations and will work with the Division to implement corrective actions.

Under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) enacted on March 27, 2020, the U.S. Department of the Interior (DOI) received $909.7 million to prevent, prepare for, and respond to the coronavirus pandemic. The Office of the Secretary (OS) received $158.4 million of the DOI’s CARES Act funding and transferred funds to the U.S. Fish and Wildlife Service (FWS), National Park Service (NPS), Bureau of Land Management (BLM), Office of Inspector General (OIG), Bureau of Reclamation (BOR), and Office of Wildland Fire (OWF). As of November 30, 2020, 5.3 percent of the funding for departmental offices had been obligated.The OS requested that the bureaus and offices formulate spend plans for allocating CARES Acts funding, including any requested transfer of funds from the OS. The Office of the Solicitor also reviewed the plans for the purpose of ensuring that the proposed spending aligned with the purposes specified in the CARES Act.All bureaus and offices are eligible for the funding appropriated to the OS; therefore, additional fund transfers can be expected through September 30, 2021. On March 27, 2020, the DOI’s Office of Budget issued a memorandum to bureaus and offices that provided initial guidance for apportionments, spend plans, and reporting requirements. The memorandum directed bureaus and offices receiving apportionments under the CARES Act to prepare draft spend plans by March 31, 2020, so the DOI could meet its April 6, 2020 deadline to provide the OMB with its apportionments. The memorandum also directed bureaus and offices to provide spend plans reflecting anticipated costs directly related to the COVID-19 response and recovery that could not be addressed through annual appropriations. The spend plans were to include allocations for the entire appropriation and estimated timeframes for completion through June 30, 2020. DOI officials stated that leadership reviewed and approved all spend plans.As requirements change, bureaus and offices are required to submit updated spend plans. All bureaus that received transferred CARES Act funds informed us that they are complying with weekly reporting requirements. The OS plans to use existing reporting mechanisms to minimize the administrative burden on the bureaus and offices.

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During our audit of the Integrity of Postal Service’s Social Media Presence, we found a smishing campaign that may have a significant negative impact on the Postal Service’s brand, reputation, and customer loyalty. The purpose of this alert is to bring this issue to your attention with a recommendation for corrective action. Smishing is a mobile phishing attack that targets victims using text messages rather than emails. These messages appear to be sent by legitimate, trusted organizations like the Postal Service. Smishing attacks attempt to trick mobile users into clicking on links that are connected to fraudulent sites that could steal credentials or propagate malware.

Amtrak (the company) contracted with the independent certified public accounting firm of Ernst & Young LLP to audit its consolidated financial statements as of September 30, 2020, and for the year then ended, and to provide a report on internal control over financial reporting and on compliance and other matters. Because the company receives federal assistance, it must obtain an audit performed in accordance with generally accepted government auditing standards. As required by the Inspector General Act of 1978, we monitored the audit activities of Ernst & Young to help ensure audit quality and compliance with auditing standards. Our monitoring focused on two Ernst & Young reports and disclosed no instances in which Ernst & Young did not comply, in all material respects, with generally accepted government auditing standards.

While U.S. Customs and Border Protection’s (CBP) actions to implement prior OIG outage-related recommendations could not have prevented the onset of the nation-wide outage on August 16, 2019, the steps taken did help minimize the length and severity of disruptions to passenger screening. By addressing OIG recommendations, CBP established a more effective control structure for monitoring passenger screening systems, thus enabling prompt action to identify and resolve the outage. However, CBP’s configuration management policies and procedures were not sufficient to prevent the 2019 outage. Specifically, CBP’s critical passenger applications were operating on an Oracle database device that was not properly configured, and, did not have up-to-date patches. The outage resulted in longer wait times and delays up to 2.5 hours for arriving passengers, as well as the need for CBP to revert to less effective backup systems to support passenger screening procedures. CBP personnel faced additional challenges during the outage, as they were unable to quickly access “offline” systems and were not fully prepared for backup procedures. This was due to inadequate training and ineffective communication from CBP Headquarters during the outage. CBP should address these deficiencies, which may increase the risk of entry of unauthorized aliens who could threaten our Nation’s security. We made five recommendations to improve training, procedures, processes, and employee awareness. CBP concurred with all five of our recommendations.

DHS OIG issued a series of three reports between August 2014 and October 2016 examining DHS’ pandemic activities, including 28 recommendations to improve the efficiency and effectiveness of DHS planning and response activities. We conducted this verification review to determine the adequacy and effectiveness of DHS’ corrective actions. We focused our review on 11 of 28 key recommendations that dealt with DHS-wide pandemic planning and response activities. We determined that DHS provided the OIG with adequate documentation of its initial plans and actions to address the recommendations to improve the Department’s pandemic planning and response. However, DHS did not effectively implement corrective actions to address three recommendations to provide the operational efficiencies and controls needed in the current pandemic. Specifically, DHS did not ensure the office it designated to manage and account for pandemic personal protective equipment provided adequate management oversight; did not ensure components’ compliance with the Integrated Logistics Support Plan; and did not designate an office to ensure continued oversight, review, and approval of the Department’s and components’ pandemic plans. We made three new recommendations to improve oversight of pandemic planning and personal protective equipment. DHS agreed with all three recommendations.

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

Under the home health prospective payment system (PPS), the Centers for Medicare & Medicaid Services pays home health agencies (HHAs) a standardized payment for each 60-day episode of care that a beneficiary receives. The PPS payment covers intermittent skilled nursing and home health aide visits, therapy (physical, occupational, and speech-language pathology), medical social services, and medical supplies.Our prior audits of home health services identified significant overpayments to HHAs. These overpayments were largely the result of HHAs improperly billing for services to beneficiaries who were not confined to the home (homebound) or were not in need of skilled services.Our objective was to determine whether Tender Touch Health Care Services (Tender Touch) complied with Medicare requirements for billing home health services on selected types of claims.

This audit report concluded that the FCC’s information security program was ineffective and not in compliance with FISMA legislation, OMB guidance, and applicable NIST Special Publications as of August 2020. Specifically, the FISMA evaluation report includes 8 findings and offers 17 recommendations intended to improve the effectiveness of the FCC’s information security program controls. The FCC has made improvements to processes within its information security program since the Fiscal Year 2019 FISMA evaluation in the areas of Identity and Access Management (i.e., separation of duties analysis, reviewing access for privileged users, and user authorization), Data Protection and Privacy (i.e., testing the FCC’s Data Breach Response Plan ), and Incident Response (i.e., documentation of incidents).

The Office of the Inspector General is required by the Federal Information Security Modernization Act of 2014 (FISMA) to conduct an annual independent evaluation that determines the effectiveness of the information security program (ISP) and practices of its respective agency. Our objective was to evaluate the Tennessee Valley Authority’s ISP and agency practices for ensuring compliance with FISMA and applicable standards, including guidelines issued by Office of Management and Budget and National Institute of Standards and Technology. Our audit scope was limited to answering the FY 2020 IG FISMA metrics developed as a collaborative effort by the Office of Management and Budget, Department of Homeland Security, and Council of Inspector Generals on Integrity and Efficiency in consultation with the Federal Chief Information Officer Council. The FY 2020 IG FISMA metrics recommend a majority of the functions be at a maturity level 4 (managed and measurable) or higher to be considered effective. Based on our analysis of the metrics and associated maturity levels defined with the IG FISMA metrics, we found TVA’s ISP was operating in an effective manner.

The Postal Service invests in facilities, vehicles, services, technology, equipment, and other resources. These resources help the Postal Service meet its customer experience, employee engagement, and revenue generation goals; and provide the Postal Service with the tools needed to maintain accountability, credibility, and competitiveness. From fiscal year (FY) 2011 to FY 2015, the Postal Service completed 48 investment projects, which were tracked in its quarterly investment compliance reports. These investments had a combined approved funding amount of about $4.2 billion. We reviewed investments over this period because the average financial projection period for investments was about 10 years and we needed data from a longer period of time to complete our assessment. Our objective was to assess whether the Postal Service achieved projected savings and ROIs identified in DAR business cases.

Fiscal Year 2020 Independent Evaluation of SEC's Implementation of the Federal Information Security Modernization Act of 2014, Report No. 563

Texas Quality Incentive Payment ProgramQIPP operates as part of the Texas Healthcare Transformation and Quality Improvement Program Waiver (the waiver), which provides health care services delivered through MCOs. QIPP is designed to improve quality and innovation in the provision of nursing facility services, and provides incentive payments to nursing facilities that meet performance requirements on specified quality measures. According to the State agency’s request to CMS for QIPP approval, payments from MCOs to qualified nursing facilities would “be based on improvements on specific quality measures.” The State agency also stated that nursing facilities “must make incremental improvements toward preset goals to qualify for payments.” Unlike the payments that were made under the UPL Program and MPAP, QIPP payments are available to private nursing facilities as well as NSGO facilities. Once appropriately claimed by the State, Federal regulations do not dictate how QIPP payments must be used by NSGE, NSGO facilities, or privately owned facilities.QIPP payments are comprised of three components. Component One payments are available only to NSGO facilities and are calculated to equal 110 percent of the IGTs that NSGEs provide to the State agency as the State share of QIPP funding. Texas defines an IGT as a “transfer of public funds” such as “taxes, assessments, levies, investments,” or “other public revenues.” Component One payments are made to NSGEs each month that NSGO facilities submit a Quality Assurance Performance Improvement (QAPI) Validation Report to the State agency. These payments are retained in full by the NSGEs. Component Two and Component Three payments are available to all QIPP-participating nursing facilities that meet individual performance requirements (described below), and are based on the amount of QIPP funding available after Component One payments are made. In addition to Component One, Component Two, and Component Three payments, all QIPP nursing facilities are eligible for “lapse funds.” Lapse funds are funds that are not distributed because one or more nursing facilities failed to meet QAPI reporting requirements or quality metrics. Lapse funds are redistributed to all nursing facilities based on each nursing facility’s proportion of the combined total QIPP-earned Component One, Component Two, and Component Three funds. MCOs retain a small percentage of the payments and lapse funds, and pay the balance to NSGEs and private nursing facilities.In its first year, 428 NSGO facilities and 85 private nursing facilities participated in QIPP, and budgeted expenditures for QIPP totaled $400 million. In the second year, 460 NSGO facilities and 95 private nursing facilities were eligible to participate in QIPP, and the budgeted expenditures totaled $446 million. On February 5, 2019, the State agency announced that it would allocate $600 million to QIPP for year 3 (State FY 2020). In the third year, 459 NSGO facilities and 339 private nursing facilities were eligible to participate in QIPP.

For our audit of the Economic Development Administration’s (EDA’s) disaster relief grants award administrative processes and oversight efforts, our objective was to determine whether EDA’s process for awarding disaster relief grants to applicants is adequate. Specifically, we focused on whether (1) EDA awarded grants on a competitive and merit basis and (2) the extent of EDA’s compliance with the requirements outlined in the Bipartisan Budget Act of 2018 as well as its own policies and procedures for determining which applicants should receive disaster relief funds.We found that EDA is awarding grants on a competitive and merit basis. However, EDA does not always comply with its own policies and procedures for determining which applicants should receive disaster relief funds. Specifically, we found that EDA did not I. ensure all applications documented a clear nexus and resilience principles; II. always use priority order of funding recommendations; and III. always meet its own internal review goals.

The VA Office of Inspector General (OIG) reviewed the measures taken by the Veterans Health Administration’s (VHA) Homeless Program Office, medical facilities, and community service providers to mitigate COVID-19 risks in transitional housing programs for veterans experiencing homelessness.The OIG found that while transitional housing service providers successfully implemented four of six specific Centers for Disease Control and Prevention (CDC) COVID-19 risk mitigation measures, the providers could have strengthened implementation of two others.VHA and service provider staff said the Homeless Program Office allowed them the flexibility to isolate vulnerable veterans, facilitate telehealth exams, and coordinate the provision of medical care in the community. Some service providers and VA medical facilities also developed their own best practices for reducing COVID-19 risks. As the pandemic continues, VHA and its service providers will need to sustain their efforts and strengthen measures to minimize COVID-19 exposure among veterans experiencing or at risk for homelessness.Staff at all 14 facilities assessed by the OIG review team made substantial progress on four measures: cleaning frequently with disinfectant, screening veterans for symptoms, creating isolation site plans, and maintaining adequate cleansing and sanitation supplies and personal protective equipment. The OIG found improved communications from the Homeless Program Office to medical facilities helped these efforts. However, several facilities appeared to struggle with the remaining two measures: identifying high-risk veterans and communicating suggested precautions and social distancing.Interviewees expressed concerns about service providers’ ability to maintain enough personal protective equipment for veterans during the prolonged pandemic. Medical facility staff will need to coordinate with service providers to help them develop contingency plans. The OIG made four recommendations to the under secretary for health regarding additional measures VHA could take to strengthen the implementation of CDC guidelines at the service providers’ facilities.

The OIG investigated anonymous allegations that a Bureau of Indian Affairs (BIA) employee and another individual engaged in inappropriate behavior with two minors under their care. We conducted this investigation with assistance from the Federal Bureau of Investigation. Our investigation found insufficient evidence to prove or disprove the allegations. We coordinated our investigation with the responsible U.S. Attorney’s Office.

The OIG investigated allegations that National Park Service (NPS) employee Stephanie Wallace used another NPS employee’s Government purchase card to make personal purchases. We found that Wallace used the employee’s purchase card to pay for her children’s private school tuition.Wallace pleaded guilty to theft of Government property. She was sentenced to 5 days of home detention and a probationary term of 1 year, and she was ordered to pay restitution totaling $8,328.24.

The Office of Refugee Resettlement (ORR), a program office of the Administration for Children and Families (ACF) within HHS, manages the Unaccompanied Alien Children Program. ORR funds a network of about 195 facilities. ORR also operates influx care facilities to provide temporary emergency shelter and services for children. ORR contracted with Comprehensive Health Service, LLC (CHS), a medical management services provider, to operate a temporary influx care facility located in Homestead, Florida. Some members of Congress have expressed concerns about ORR’s awarding of a $341 million sole source contract to CHS.

The information security program of the Corporation for National and Community Service, now called AmeriCorps, remains Not Effective and has shown little progress over the past four years. While AmeriCorps has demonstrated some improvement on configuration management, key areas of organization-wide risk management strategy, standard baseline configurations, Personal Identity Verification (PIV) multifactor authentication, and vulnerability and patch management have remained stagnant at a low level of maturity. AmeriCorps continues to suffer a significant number of critical and high-risk vulnerabilities, which were not mitigated within the prescribed deadlines commensurate with their importance. Nor has AmeriCorps made significant progress in closing prior recommendations. Since last year, only eleven of the 58 open recommendations from the FY 2014 – FY 2019 FISMA evaluations have been resolved, yielding limited improvements in FISMA metric results. An inability to address critical deficiencies leaves AmeriCorps systems and data vulnerable to data breaches, which may expose sensitive information, including Personally Identifiable Information, to unauthorized access, use and disclosure. Our report offers nine recommendations (eight new and one modified repeat), which, together with the prior year recommendations, will assist AmeriCorps in addressing challenges in the development of a mature and effective information security program. AmeriCorps has committed to implementing corrective actions to our recommendations.

EAC OIG, through the independent public accounting firm of Brown & Company, PLLC, audited EAC's compliance with the Federal Information Security Modernization Act of 2014 (FISMA) and related information security policies, procedures, standards, and guidelines for fiscal year 2020.

The VA Office of Inspector General (OIG) conducted a review of the Veterans Health Administration’s response to anticipated demand and use of emergency department and urgent care center services when faced with the possibility of an influx of patients needing evaluation during the COVID-19 pandemic. A survey was deployed and 63 emergency department and urgent care center directors were interviewed.The OIG learned there was a decreased number of patient visits to the emergency departments (19.8 percent decline) and to the urgent care centers (28.6 percent decline) for January–June 2020 when compared with the same time frame in 2019.Other issues described by interviewees included a small number of rooms with negative pressure and small waiting rooms that made it difficult to isolate or separate patients with known or suspected COVID-19. Twenty-three emergency department and urgent care center directors reported a loss of staff due to providers testing positive for the virus, transfers, resignations, or retirements. COVID-19 testing was generally available at the selected facilities. Some directors reported a lack of or need to ration certain items of personal protective equipment. Regular communications with leaders that addressed the most recent COVID-19 topics were informative and helpful.Data related to supplies, clinical treatment, COVID-19 epidemiology, and hospital utilization were deemed critical and helpful for decision making. Virtually all respondents stated that they closely monitored staff for signs of fatigue and burnout.Lessons learned included patient and provider COVID-19 education, rethinking how emergency or urgent care can be delivered in a pandemic, and redesigning the day-to-day operations of the work place. The directors also noted the need to preserve the capability to provide emergency or urgent care for non-COVID-19 patients while attending to the special care needs of patients with COVID-19.

We audited information systems controls over the U.S. Department of Housing and Urban Development’s (HUD) computing environment as part of the internal control assessments for the fiscal year 2019 financial statements audit under the Chief Financial Officer’s Act of 1990. Our objective was to assess general controls over HUD’s computing environment for compliance with HUD information technology policies and Federal information system security and financial management requirements. We focused our assessment on the general controls over HUD’s IBM mainframe general support system.The OIG has determined that the contents of this audit report would not be appropriate for public disclosure and has therefore limited its distribution to those officials listed on the report distribution list.

The Office of the Inspector General conducted a review of the Commercial Energy Solutions Origination and Renewables (O&R) organization to identify factors that could impact O&R’s organizational effectiveness. During the course of our evaluation, we identified behaviors that had a positive impact on O&R. These included interactions with team members and leadership. While O&R met targets for a majority of their metrics and furthered initiatives within the organization, we also identified risks to business operations and achievement of future O&R initiatives. These included educational needs, such as the need for training and the lack of documented processes and procedures, technology needs, and insufficient staffing for the future within and outside O&R. In addition, business partners discussed areas for improvement, including collaboration and O&R strategy.

In March 2020, the World Health Organization declared the coronavirus (COVID-19) outbreak a global pandemic. The Tennessee Valley Authority (TVA) began taking steps to keep employees and their families’ safe, while also ensuring the agency could fulfill its mission of service. Due to the ongoing pandemic and its impact on TVA’s workforce related to mandatory telework and staffing, we initiated an evaluation to assess TVA’s response to COVID-19. The objective of our evaluation was to assess TVA’s response to COVID-19. Our scope included actions taken by TVA related to staffing, employee safety, telework, and lessons learned. We determined most actions taken by TVA in response to COVID-19 related to staffing, employee safety, and telework were reasonable. Specifically, (1) TVA’s policies align with the Centers for Disease Control and Prevention and federal guidelines, (2) TVA took actions to document and communicate lessons learned, (3) feedback from employees and management was positive regarding changes made in response to COVID-19 on employees and their work. However, we identified potentially misleading marketing language used to promote unproven technology to combat COVID-19. In addition, we identified some opportunities for improvement related to extended telework, mask usage at TVA facilities, and information management practices. Additionally, we identified some required elements were not present in the continuity of operations plan for TVA’s River Forecast Center.

The Office of Inspector General (OIG) is initiating an audit of the AbilityOne ComplianceProgram. Our overall objective is to determine whether the Compliance Program has beenimplemented effectively to provide reasonable assurance of nonprofit agency and centralnonprofit agency compliance with applicable laws, regulations, and policies. To answer ouraudit objective, we will 1) review laws, regulations, policies, and procedures applicable tothe Compliance Program, 2) conduct interviews with key personnel, and 3) analyze data,reports, and other supporting documentation related to compliance reviews.

What We Looked AtAccording to U.S. Bank, Department of Transportation (DOT) employees made more than 1.1 million travel card transactions--totaling $180 million--in calendar year 2019. In 2014, we reported on internal control weaknesses in the Department's travel card program and found that excessive or unauthorized cash advances and instances of travel card misuse sometimes went undetected because DOT lacked robust internal controls to prevent these transactions. In addition, our annual charge card risk assessments disclosed areas that constitute risk to the Department's charge card program such as outdated and incomplete policies, overdue travel card training, and a travel card account that remained active after a travel cardholder (TCH) separated from the Agency. As a result, we determined that another audit of this program was needed. Accordingly, our objective was to determine whether DOT's internal controls for its travel card program are effectively designed and operating efficiently to prevent and detect travel card misuse and abuse.What We FoundWe identified internal control weaknesses that prohibit DOT from preventing or detecting the inappropriate use of travel cards. These weaknesses have resulted in TCHs not consistently following existing controls, increasing the risk of travel card misuse and abuse. Specifically, based on our findings for 71 of the 793 travel card transactions in our samples, TCHs did not always follow prescribed controls for an estimated $18.6 million in purchases. Furthermore, we found that TCHs did not use their Government travel cards to pay for $28 million in official travel related expenses, thus preventing DOT from receiving the total amount of rebates it would be eligible to receive.RecommendationsWe made 11 recommendations to assist DOT in increasing the effectiveness of its internal controls. DOT fully concurred with the all of our recommendations, and we consider them resolved but open pending completion of the planned actions.

Our previous work at other hospitals identified these types of hospital claims, among others, that were at risk for noncompliance:• inpatient claims billed with elective surgical procedures,• inpatient claims billed with high-risk DRG codes, • inpatient claims billed with high-severity-level DRG codes,• inpatient claims billed for mechanical ventilation, and • outpatient claims with payments greater than $25,000.For the purposes of this report, we refer to these areas at risk for incorrect billing as “risk areas.” We reviewed these risk areas as part of this audit. Medicare payments may not be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” (Social Security Act (the Act) § 1862(a)(1)(A)). In addition, the Act precludes payment to any provider of services or other person without information necessary to determine the amount due the provider (§ 1815(a)).Federal regulations state that the provider must furnish to the Medicare contractor sufficient information to determine whether payment is due and the amount of the payment (42 CFR § 424.5(a)(6)).Claims must be filed on forms prescribed by CMS in accordance with CMS instructions (42 CFR § 424.32(a)(1)). The Medicare Claims Processing Manual (the Manual) requires providers to complete claims accurately so that Medicare contractors may process them correctly and promptly (Pub. No. 100-04, chapter 1, § 80.3.2.2). The Manual states that providers must use HCPCS codes for most outpatient services (chapter 23, § 20.3). The Office of Inspector General (OIG) believes that this audit report constitutes credible information of potential overpayments. Upon receiving credible information of potential overpayments, providers must exercise reasonable diligence to identify overpayments (i.e., determine receipt of and quantify any overpayments) during a 6-year lookback period. Providers must report and return any identified overpayments by the later of (1) 60 days after identifying those overpayments or (2) the date that any corresponding cost report is due (if applicable). This is known as the 60-day rule. The 6-year lookback period is not limited by OIG’s audit period or restrictions on the Government’s ability to reopen claims or cost reports. To report and return overpayments under the 60-day rule, providers can request the reopening of initial claims determinations, submit amended cost reports, or use any other appropriate reporting process. The Hospital is a 171-bed hospital located in Kansas City, Kansas. According to CMS’s National Claims History (NCH) data, Medicare paid the Hospital approximately $124 million for 11,128 inpatient and 53,868 outpatient claims between January 1, 2016, and December 31, 2017 (audit period).

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 and who have elected hospice care. Previous OIG reviews found that Medicare inappropriately paid for hospice services that did not meet Medicare requirements.Our objective was to determine whether hospice services provided by Hospice Compassus, Inc., of Tullahoma, Tennessee (Tullahoma), complied with Medicare requirements.

The VA Office of Inspector General (OIG) conducted a rapid response healthcare inspection at the Charlie Norwood VA Medical Center in Augusta, Georgia, to assess allegations from an anonymous complainant that deficiencies in care coordination between facility staff and remote telemedicine intensive care unit (tele-ICU) staff resulted in deaths, injuries, or poor outcomes for patients in the critical care unit (CCU) after general surgery residents were withdrawn. The names of six patients were included in the complaint. The OIG substantiated that deficiencies in care coordination existed between facility staff and tele-ICU staff after the residents were withdrawn but was unable to determine that the withdrawal resulted in deaths, injuries, or poor outcomes for patients identified in the complaint. The OIG found that facility leaders were aware of the potential withdrawal of the residents but did not take actions to ensure that effective processes were in place and failed to be proactive in developing, disseminating, and ensuring effectiveness of relevant algorithms.The OIG also found a combination of a misunderstanding of the tele-ICU program and a lack of facility staff engagement with tele-ICU staff to assist with co-management of monitored patients contributed to challenging and impaired communication processes. The tele-ICU was not integrated into facility quality management processes and facility staff and tele-ICU staff did not report, and therefore patient safety staff did not evaluate, tele-ICU patient safety events.Six recommendations were made to the Facility Director related to communication and coordination, on-call processes, medicine and surgery staff responsibilities, patient safety reporting training, quality review collaboration processes, and orientation and competency training. Two recommendations were made to the Veterans Integrated Service Network 10 Tele-ICU Medical Director related to patient safety reporting training and coordination of patient care reviews.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Charlie Norwood VA Medical Center and multiple outpatient clinics in Georgia and South Carolina. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; 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.The executive leadership team had worked together for seven months at the time of the OIG’s visit. Survey results revealed opportunities for the Director to improve employee satisfaction. Survey data also indicated that patients were somewhat satisfied with their care. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial risk factors. However, the OIG identified significant concerns with equipment purchased and corresponding lack of full implementation. Executive leaders were able to speak knowledgeably about actions taken during the previous 12 months to maintain or improve performance. Leaders were also knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models.The OIG issued 20 recommendations for improvement in five areas:(1) Quality, Safety, and Value• Committee processes• Peer review• Root cause analyses(2) Medical Staff Privileging• Exit review process(3) Environment of Care• Environmental safety and cleanliness• Information protection(4) Women’s Health• Gynecological care coverage• Women’s health providers and clinical liaison(5) High-Risk Processes• Standard operating procedures• Risk analysis• Equipment storage• Staff training

The Katy Carrier Annex is in the Houston District of the Southern Area. The unit has 48 city routes, 32 rural routes, and seven contract routes delivered by 62 city carriers, 49 rural carriers, and seven contract carriers. We chose the Katy Carrier Annex based on the number of stop-the-clock (STC) scans occurring at the delivery unit. Our objective was to evaluate select mail delivery and customer service operations at the Katy Carrier Annex.

Our objective for this report was to complete our review of the company’s use of Coronavirus Aid, Relief, and Economic Security (CARES) Act funds and its controls to accurately track and report on them.We found that the company is effectively using, accounting for, and reporting on the $1.018 billion it received through the CARES Act, and that it has addressed the initial risks we identified in our interim report published in August 2020. If Congress approves additional assistance, we identified two opportunities for the company to adjust its controls for approving paid leave for coronavirus-related absences and applying the CARES Act formula for calculating state bills for services provided under section 209 of the Passenger Rail Investment and Improvement Act of 2008. These adjustments would make the controls more consistently effective.

We determined if FS had the proper authority and followed Federal laws and regulations when awarding a $2 million grant to the State of Alaska.

An Amtrak Police Department employee resigned on December 15, 2020, in lieu of a disciplinary hearing for violating various company policies. Our investigation found that the employee engaged in outside employment during his shifts and while on sick leave. In doing so, the employee also violated his union agreement. The employee shopped online and left for long periods of time to purchase supplies for his outside employment during his APD shifts and engaged in his outside employment while the company was paying him to attend mandatory training. During the training, he took significant steps to hide these actions from being discovered.

The OIG investigated allegations that Extraction Oil and Gas (EXT) drilled multiple horizontal wellbores through a railroad right-of-way (ROW) in Weld County, CO, containing Federal minerals without first obtaining a Federal lease or drilling permit.We found that three companies (EXT, Mineral Resources, Inc., and PDC Energy, Inc.) illegally drilled oil wells through a railroad ROW and produced unleased Federal minerals. Based on our investigation, the U.S. Attorney’s Office for the District of Colorado entered into civil settlement agreements with all three companies to resolve the violations and recover public revenues. The settlements totaled more than $1,787,000.

We considered Recommendation 5 resolved and implemented and Recommendations 1 – 4 and 6 – 8 resolved but not implemented. We referred those seven recommendations to the Assistant Secretary for Policy, Management and Budget to track their implementation.

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE.This report presents the DOI’s progress as of October 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $566,168,083, and its obligations total $661,068,678.We are also monitoring the DOI’s progress on reporting milestones established by the CARES Act and the U.S. Office of Management and Budget.We anticipate issuing updated status reports monthly.

We audited the costs claimed by the Commonwealth of Massachusetts, Division of Marine Fisheries, under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program. We conducted this audit to determine whether the Division used grant funds and fishing license revenue for allowable fishing activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. The audit period included claims totaling $3 million on nine grants that were open during the Commonwealth’s fiscal years that ended June 30, 2018, and June 30, 2019.We found that the Division ensured that grant funds and license revenue were used for allowable activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. We did not identify any reportable conditions. We also followed up on seven recommendations from our 2010 and 2016 audits and found that the U.S. Department of the Interior’s Office of Policy, Management and Budget considered all recommendations resolved and implemented. We did not require a response to this audit report.

We audited the costs claimed by the Commonwealth of Virginia, Marine Resources Commission, under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program. We conducted this audit to determine whether the Commission used grant funds and State fishing license revenue for allowable fish activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. The audit period included claims totaling $7.6 million on 22 grants that were open during the State fiscal years that ended June 30, 2018, and June 30, 2019.We found that the Commission ensured that grant funds and license revenue were used for allowable activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. We did not identify any reportable conditions.

We audited the costs claimed by the Pennsylvania Game Commission under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program. The audit included claims totaling approximately $82.7 million on 17 grants that were open during the State fiscal years that ended June 30, 2017, and June 30, 2018. The audit also covered the Commission’s compliance with applicable laws, regulations, and FWS guidelines, including those related to collecting and using hunting and fishing license revenues and reporting program income.We found that the Commission claimed ineligible and unsupported costs to Program grants totaling $7,329,212 ($1,127,981 Federal share). These questioned costs related to equipment usage rates, other direct costs, subaward costs, in-kind contributions, payroll costs, and program income.We also found that the Commission did not properly allocate credit card rebates among applicable grants, improperly classified subawards as contracts, did not adequately manage equipment, misused Program-funded real property, did not report barter transactions, and did not protect lands acquired or maintained with Program funds or license revenues against trespass and encroachment.We made 29 recommendations and 1 repeat recommendation. In response to our draft report, the FWS provided a list of corrective actions and stated it will work with the Commission to implement them.

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 Wm. Jennings Bryan Dorn VA Medical Center and multiple outpatient clinics in South Carolina. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; 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.The medical center leaders had worked together for nearly two years at the time of the on-site inspection. Survey results indicated that employees were generally satisfied. However, patient survey results indicated multiple opportunities for medical center leaders to improve satisfaction. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. Medical center leaders, other than the Chief of Staff, were knowledgeable within their scope of responsibilities about employee and patient satisfaction survey results and Veterans Health Administration data and/or factors contributing to specific poorly-performing Strategic Analytics for Improvement and Learning quality and efficiency measures.The OIG issued 14 recommendations for improvement in six areas:(1) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit reviews(2) Environment of Care• Infection prevention and medication safety• Environmental cleanliness• Privacy(3) Medication Management• Aberrant behavior risk assessment• Informed consent• Patient follow-up (4) Mental Health• Patient follow-up• Suicide prevention training(5) Women’s Health• Gynecologic care coverage• Women Veterans Health Committee membership and attendance(6) High-Risk Processes• Equipment storage