Federal Reports

We investigated allegations that two National Park Service (NPS) managers violated contracting regulations and procedures by using the Standard Form 182 (SF-182), which is meant to fund standardized training, to pay a company for extended work on an internal NPS training website. We also investigated allegations that NPS employees improperly hired NPS retirees and then re-issued or re-activated their Personal Identity Verification (PIV) cards.We found that the two NPS managers, who oversaw aspects of NPS training programs, improperly used the SF-182 to pay a company $1,041,117 to develop and maintain an internal training website, circumventing contracting regulations. The two NPS managers have since left the agency.We also found that one of the managers retained his PIV card after retiring and had another employee re-enable the card after he left Federal service, in violation of departmental policy. We also discovered a separate instance in which an NPS retiree performed fiscal and budget-related services for an NPS training center without a contract. The NPS retiree received a new PIV card under the guise of an unrelated contract.

The OIG investigated an allegation that an employee with the Office of the Assistant Secretary for Indian Affairs (AS-IA) may have improperly used entities that he owned or had a financial interest in to perform work at the U.S. Department of the Interior (DOI).We found that the employee was involved in choosing two unregistered entities with whom he or other DOI staff had personal relationships and repeatedly paid them with a charge card, rather than establish a contract as required. The employee violated DOI policy and Federal regulations by misusing his Government charge card; asking for and receiving cash from the entities while they performed work for the DOI; issuing numerous payments to the entities with no supporting documentation; and submitting altered invoices during an internal charge card review as support for payments he made. We also found the employee personally received funds from the DOI for a private group he operated, and he did not file a financial disclosure as required by his position.The U.S. Department of Justice declined prosecution and the employee left Federal service.

The VA Office of Inspector General (OIG) conducted this review to determine whether Veterans Benefits Administration (VBA) decision makers accurately completed disability evaluations for veterans’ service-connected heart disease. The OIG estimated VBA decision makers incorrectly evaluated about 12 percent of claims for heart disease between November 1, 2018, and April 30, 2019. Of those, about 870 resulted in improper payments totaling at least $5.6 million. VBA decision makers inappropriately evaluated heart disease using information from disability benefits questionnaires filled out either by VA or contracted medical providers. Decision makers also made other inaccurate decisions on claims. The OIG determined that the disability benefits questionnaire format contributed to the inappropriate evaluations of veterans’ heart conditions. The system-generated instructions for the questionnaire prompted unclear medical statements. VBA decision makers did not consistently ask for the clarification they needed to make accurate disability determinations. The OIG made three recommendations for improving the handling of disability benefits questionnaires for heart diseases to ensure they are properly filled out with unambiguous and consistent information. The OIG made no recommendation on the inaccurate claims decisions because the review team did not identify a common trend or pattern for these errors.

The VA Office of Inspector General (OIG) assessed an allegation that providers permitted an individual with no legal authority to make medical decisions on behalf of a patient. The patient had a three-week medical and mental health hospitalization with repeated episodes of confusion, agitation, and combative behavior. The patient was transferred to hospice care and died five days later. The OIG substantiated the patient’s neighbor had no legal authority but made medical decisions. The OIG noted clinical and patient rights deficiencies and reviewed facility leaders’ evaluation of the deficiencies in the patient’s care. Facility staff did not take the required appropriate steps to identify and confirm the eligibility of this surrogate. Staff searched the patient’s belongings and records, but they did not review other VA records. Three days after the patient’s death, administrative staff located a family member from VA benefits records. The OIG determined that records did not contain sufficient documentation of physicians’ clinical assessments to support diagnoses and treatment decisions. Clinical communication and collaboration were inconsistent, insufficient, and negatively impacted the patient’s continuity and quality of care. Providers did not consistently document medication monitoring and oversight activities to ensure safe patient care. The OIG concluded the patient’s transfer to hospice was completed without fully pursuing other diagnoses and treatment options and staff did not ensure the patient’s rights were upheld regarding involuntary admission and behavioral restraints. Facility leaders did not complete a thorough quality of care review to understand the reasons for the patient’s atypical hospital course and outcome. The OIG made 15 recommendations to the Facility Director related to the patient’s decisional capacity, surrogate identification, medical assessments, medication management, and hospice admission. Other areas of focus included patient rights, quality management processes, and institutional disclosure.

A majority of U.S. customers are concerned about the environmental impact of deliveries and many factor in these concerns when choosing a delivery company.To respond to customers’ expectations the Postal Service — like competitors and international posts — could consider offering optional carbon compensation offsets for its letters and parcels, as well as reusable packaging solutions.

The objective for this management advisory report was to monitor and assess how the company is using CARES Act funds and the controls it has in place to accurately account for and report on them.The company experienced a sharp drop in ridership and passenger revenues in March 2020 as a result of the coronavirus pandemic. The company’s response included aggressive cost-cutting actions such as cancelling some of its train service and reducing management pay and retirement benefits. Despite these actions, the company projected that revenues would still not cover its reduced costs and requested assistance from Congress. Congress responded by providing the company with $1.018 billion through the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) to “prevent, prepare for, and respond to” the coronavirus pandemic.On April 16, 2020, we began an audit to monitor and assess how the company is using CARES Act funds and the controls it has in place to accurately account for and report on them. So far, the company’s initial steps to use, account for, and report on the CARES Act funds are encouraging. By its actions, the company appears committed to providing transparency and demonstrating fiscal responsibility over its use of these funds. We identified three areas where additional focus could reduce risks. Going forward, a focus on providing more transparent data on how changes in service will affect state costs will help states as they develop their own budgets. In addition, a more-timely verification of pandemic-related expenses will help demonstrate that the company is being a responsible steward of taxpayer dollars. This is especially important considering that the company has requested $1.475 billion in supplemental funding for FY 2021 to mitigate expected shortfalls in passenger revenue. Finally, ensuring that adequate controls are in place to safeguard scarce pandemic-related materials and equipment throughout all links in the supply chain will ensure that these products are available to support the safety and health of the company’s workers and the traveling public.

Prior OIG audits identified Medicare overpayments to hospitals that did not comply with Medicare's post-acute-care transfer policy (transfer policy). CMS generally concurred with our recommendations, but subsequent analysis that we conducted indicated that CMS's system edits were still not properly designed and that hospitals may be using condition codes to bypass CMS's system edits to receive higher reimbursements for inpatients transferred to home health services.

What We Looked AtWe queried and downloaded 95 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between April 1, 2020 and June 30, 2020, to identify significant findings related to programs directly funded by the Department of Transportation (DOT). What We FoundWe found that reports contained a range of findings that impacted DOT programs. The auditors reported significant noncompliance with Federal guidelines related to 21 grantees that require prompt action from DOT’s Operating Administrations (OA). The auditors also identified questioned costs totaling $3,440,165 for 10 grantees. RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $3,440,165, if applicable.

The VA Office of Inspector General (OIG) received allegations of inadequate orientation and training of pharmacy staff, a lack of pharmacist oversight of intravenous (IV) admixtures, and noncompliance with controlled substance policies. The Veterans Integrated Service Network Director initially reviewed the matter and did not substantiate the allegations but noted that some pharmacy staff’s annual IV compounding competencies had lapsed. The OIG received a second allegation that pharmacy management was noncompliant with Veterans Health Administration (VHA) controlled substance policies and initiated a healthcare inspection to evaluate the allegations and review the annual IV compounding competencies. The OIG did not substantiate inadequate pharmacist orientation and training for inpatient pharmacy, IV admixture, and the cache, and did not substantiate a lack of pharmacist oversight in technician-prepared IV admixtures. The annual required staff competencies were current. However, the OIG team noted the orientation checklists and annual competencies lacked a tracking mechanism. Pharmacy managers complied with the VHA controlled substance directive. The OIG team learned of a suspected controlled substance diversion incident that facility leaders reported to the VA police and the OIG Office of Investigations but did not report to the email group required by the VHA directive at the time. The OIG team learned of an instance where testosterone was not added to inventory records or secured in the vault. The OIG made three recommendations to the Facility Director related to developing a tracking process for orientation and annual competencies of pharmacy staff, ensuring facility leaders are trained on current VHA drug diversion reporting requirements, and conducting a review of the testosterone misplacement. Note: This matter is not related to the recent criminal case involving a former nursing assistant at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

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 William S. Middleton Memorial Veterans Hospital and multiple outpatient clinics in Illinois and Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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 appeared stable, with all positions assigned. Survey results indicated that employees were generally satisfied and seemed consistent with the medical center’s high-performing Best Place to Work performance measure. Patient survey results were notably higher than corresponding VHA averages; however, female patients were generally less satisfied. The OIG identified concerns with poor communication among program leaders as a vulnerable area for the medical center. Executive leaders were generally knowledgeable about Strategic Analytics for Improvement and Learning measures and should continue to take actions to improve and sustain performance. The OIG issued 16 recommendations for improvement in six areas: (1) Quality, Safety, and Value • Improvement action implementation • Utilization management data review (2) Medical Staff Privileging • Professional practice evaluation processes • Provider exit review forms (3) Environment of Care • Medical equipment inspections • Medication storage (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up after therapy initiation (5) Mental Health • Staff training (6) High-Risk Processes • Annual risk analysis • Traffic flow restriction • Temperature and humidity monitoring • Staff competency and continuing education

The Social Security Act requires that each Medicare administrative contractor (MAC) have its information security program evaluated annually by an independent entity. The Centers for Medicare & Medicaid Services (CMS) contracted with Guidehouse, LLP (Guidehouse), to evaluate information security programs at the MACs, using a set of agreed-upon procedures (AUPs). HHS OIG must submit to Congress annual reports on the results of these evaluations, to include assessments of their scope and sufficiency. This report fulfills that responsibility for fiscal year 2019.

The OIG investigated allegations that Bureau of Indian Education (BIE) Facilities employees Simon Nunez, David Parrish, and Leland Martinez and San Felipe School employees Ruby Montoya and Nancy Nunez made personal purchases on their assigned Government charge cards.Parrish and Martinez admitted to purchasing personal items, including sheds, tankless water heaters, computers, and tools, with their Government purchase charge cards between August 2013 and December 2016. Simon Nunez, a BIE Facilities Manager, directed the purchases and kept some of the stolen property. Nunez purchased three computers, two of which she converted for personal use and one of which she gave to Montoya to be converted to personal use. Montoya authorized Nunez to purchase one computer, which Montoya converted to personal use.Simon Nunez pleaded guilty in U.S. District Court for the District of New Mexico to nine counts of theft, conspiracy, and false statements. He was sentenced to 6 months in prison followed by 24 months of supervised release and was ordered to pay $6,664.52 in restitution, a $900 special assessment, and a $5,000 fine. Simon Nunez left Federal service on December 23, 2016.Parrish pleaded guilty in U.S. District Court for the District of New Mexico to four counts of conspiracy and theft. He was sentenced to 18 months of probation and was ordered to pay $2,035.51 in restitution, a $400 special assessment, and a $2,500 fine. Parrish left Federal service on December 23, 2016.Martinez pleaded guilty in U.S. District Court for the District of New Mexico to five counts of conspiracy and theft. He was sentenced to 24 months of probation and was ordered to pay $2,895 in restitution, a $500 special assessment, and a $500 fine. Martinez left Federal service on November 6, 2019.Montoya pleaded guilty in U.S. District Court for the District of New Mexico to unlawful conversion of government property and was sentenced to 12 months of probation and was ordered to pay a $2,000 fine. Montoya left Federal service on February 10, 2017.Nancy Nunez pleaded guilty in U.S. District Court for the District of New Mexico to three counts of unlawful conversion of government property and was sentenced to 24 months of probation and was ordered to pay a fine of $8,879 and a special assessment of $300. Nancy Nunez left Federal service on April 14, 2017.

We investigated allegations that Lawrence Killsback, while serving as President of the Northern Cheyenne Tribe (NCT), submitted fraudulent travel claims. The funds used to pay the fraudulent claims came from federally funded NCT programs. Our investigation focused on Killsback’s regional travel in Montana, Wyoming, and South Dakota. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) conducted a parallel investigation that focused on Killsback’s remaining domestic trips.Together, the parallel investigations found that Killsback stole over $20,000 from NCT programs by submitting multiple fraudulent travel vouchers between August 18, 2014, and August 25, 2017.This investigation was prosecuted jointly with the HHS OIG investigation. Killsback pleaded guilty in U.S. District Court for the District of Montana to one count of wire fraud in violation of 18 U.S.C. § 1343 and one count of false claims conspiracy in violation of 18 U.S.C. § 286. On December 12, 2019, Killsback was sentenced to 6 months in prison and 3 years of supervised release. Killsback was also ordered to pay a $200 special assessment and $25,092 in restitution.

The Postal Accountability and Enhancement Act of 2006 requires that each class of mail or type of mail service covers their direct and indirect costs. Over the past 10 years, several U.S. Postal Service market dominant products continuously failed to cover their attributable costs. Currently there are six market dominant products that are not covering their direct and indirect costs (underwater products). In fiscal year (FY) 2019, total loss from these underwater products was about $1.6 billion. Further, some market dominant mail products have had notable declines in cost coverage over the last 10 years. Unlike competitive products, market dominant product price increases are restricted to the Consumer Price Index, with a price cap applied to each mail class. Our objective was to evaluate opportunities to reduce mail product costs. This audit was initiated to review cost reduction initiatives specific to underwater products; however, the issues we identified impacted more than just underwater products.

Nurse staffing is a key contributor to the quality of care provided in nursing homes. This review, initiated before the COVID-19 pandemic emerged, focuses on staffing data from 2018. However, the 2020 pandemic reinforces the importance of adequate staffing for nursing homes, as inadequate staffing can make it more difficult for nursing homes to respond to infectious disease outbreaks like COVID-19.

This is an audit of NEA's Information System contracts. Due to security concerns, this information is not published on the internet. You can obtain a copy of the memorandum through a freedom of information act request at the following link: https://www.arts.gov/freedom-information-act-guide.

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.

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

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), which provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.As part of the $756 million, the Office of the Secretary received $157.4 million to prevent, prepare for, and respond to the coronavirus across DOI operations, which includes wildland fire management. The DOI approved $11.3 million in funding for the DOI’s Wildland Fire Management (WFM) program through September 30, 2020.The DOI’s WFM program is composed of the four bureaus with wildland fire management responsibilities—the Bureau of Indian Affairs (BIA), the Bureau of Land Management (BLM), the National Park Service (NPS), and the U.S. Fish and Wildlife Service (FWS)—and the Office of Wildland Fire (OWF), which is responsible for program coordination, accountability, and oversight of the WFM program budget. The OWF coordinated a fire management request for CARES Act funding on behalf of the WFM program. The OWF request provided estimates of items needed upfront, as well as items needed on an ongoing basis through the end of the fiscal year. As of June 19, 2020, the DOI had approved $11.3 million, and the WFM program had obligated $547,596 (or 5 percent) and spent $381,431 (or 3 percent) of those approved funds. The CARES Act requires agencies to obligate all appropriations by September 30, 2021.

In efforts to provide FEC management insight into the TRANServe program’s internal controls and operations, the OIG sought answers to the following questions: Did FEC employees misuse their TRANServe benefits during the FY 19 shutdown?Has management established adequate internal controls to monitor compliance with FEC Commission Directive 54, Employee Transit Benefit Program?As a result, we developed three recommendations to improve the operations and monitoring of the FEC TRANServe Program. These recommendations serve to enhance the integrity and effectiveness of the FEC TRANServe Program and the accuracy of the agency transit subsidy allocations.

We contracted with RMA Associates, LLC, an independent certified public accounting firm, to conduct the FY 2019 improper payments risk assessment for the National Endowment for the Arts (Arts Endowment) in compliance with the Improper Payments Elimination and Recovery Act (IPERA). IPERA defines significant as improper payments that exceed $10 million and 2.5 percent of the program’s total expenditures or $100 million regardless of the proportion to the program’s total expenditures. RMA performed a risk assessment to determine if the Arts Endowment’s grants program is susceptible to improper payments. In performing the assessment, RMA only assessed inherent risk. Based on the assessment of inherent risk, four potential areas of risk were identified: $7.3 million were sourced from manual invoice entries; $4.3 million payments were held; $74.4 million transactions were created by one user; and $5.3 million of vendor payments were flagged as suspicions payments.

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The VA Office of Inspector General (OIG) conducted a review at the Ioannis A. Lougaris VA Medical Center in Reno, Nevada. The review proactively identified and evaluated declining performance metrics that could affect quality of care and patient safety. The OIG selected the facility because, according to Strategic Analytics for Improvement and Learning data, quality performance significantly declined over a 12-month period at a rate faster than other VA facilities. In addition to leaders’ awareness of, and response to, negative performance trending, the review examined performance in six quality measure domains—Access, Performance Measures, Mental Health, Emergency Department Throughput, Patient Experience, and Employee Satisfaction. The OIG did not find evidence of large-scale system or process deficits such as dysfunctional organizational or communication structures. Two conditions were identified that possibly established the basis for the facility’s performance measure decline from October 1, 2017, through September 30, 2019. Leaders and managers acknowledged losing focus on some care processes as their attention was diverted to new or priority initiatives. The facility also lacked consistently effective structures and processes for oversight, communication, and follow-up of performance measures and related activities, so the loss of focus and decline in some measures was not identified timely. The OIG found staffing, pay issues, and inefficient processes that may have contributed to some of the decline. This review assisted the OIG to understand underlying issues and processes that may contribute to significant performance deficits, which will, in turn, permit the OIG to further develop and refine tools to provide a more effective and proactive approach to other OIG oversight products. The OIG made one recommendation for the Facility Director to ensure that mechanisms to report and follow up on performance deficits were well defined and disseminated to staff, and that monitors were in place to confirm functionality.

Our objective was to answer questions on the Social Security Administration's (SSA) implementation of iPaySSA.

Our objective was to determine whether the Social Security Administration (SSA) could effectively determine the accuracy of Supplemental Security Income (SSI) recipients' reports of separation from individuals whose income could affect their eligibility for payments.

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

We audited the costs claimed by the by the State of West Virginia, Division of Natural Resources (Division), 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 $46.2 million on 29 grants that were open during the State fiscal years that ended June 30, 2017, and June 30, 2018. The audit also covered the Division’s compliance with applicable laws, regulations, and FWS guidelines, including those related to the collection and use of hunting and fishing license revenues and the reporting of program income.We found that the Division complied, in general, with applicable grant accounting and regulatory requirements. The Division, however, did not report barter transactions on the financial reports to the FWS as required. In addition, the Division and the FWS did not complete a required reconciliation of their respective real property inventories. The FWS concurred with our three recommendations and will work with the Division to implement corrective actions.

We audited costs claimed by the Alabama Department of Conservation, Marine Resources Division (Department), under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program (WSFR). The audit period included claims totaling $5.1 million on 23 grants that were open during the State fiscal years that ended September 30, 2017, and September 30, 2018. The audit also covered the Department’s compliance with applicable laws, regulations, and FWS guidelines, including those related to collecting and using fishing license revenues and reporting program income.We found that the Department generally ensured that grant funds and State fishing license revenue were used for allowable fish activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. We noted, however, the Marine Resources Division purchased items with grants funds that were unallowable, and we questioned $3,112 ($2,334 Federal share) in ineligible costs associated with these purchases. We also found that the Department overdrew $5,164 ($3,873 Federal share) from a grant because the Department failed to appropriately report program income. We further determined the Department did not comply with Digital Accountability and Transparency Act of 2014 requirements by not reporting subawards greater than $25,000 on USASpending.gov.The FWS concurred with all five recommendations and will work with the Department to implement them. Based on the Department’s and FWS’ responses, we considered Recommendation 2 resolved and implemented and Recommendations 1 and 3 – 5 resolved but not implemented.

We conducted an audit of the National Endowment for the Arts (Arts Endowment) charge cards to determine if transactions follow requirements outlined in the Government Charge Card Abuse Prevention Act of 2012. We tested transactions made using Arts Endowment purchase charge cards (“purchase cards”) and travel charge cards (“travel cards”), collectively charge cards, that occurred during fiscal year (FY) 2019. Our audit concluded the following: one purchase card holder did not have a training certificate indicating the employee completed appropriate training; the monthly billing statement for one purchase card transaction was not countersigned by the corresponding Approving Official, per the Arts Endowment Credit Card Holders & Purchase Limits Table; Arts Endowment did not conduct a periodic review to determine whether travel cards are necessary for all travel card holders; Arts Endowment did not conduct a periodic review to determine whether purchase cards are necessary for all purchase card holders; two travel card transaction subsamples occurring in September 2019 did not have associated vouchers; and Subsample 27.2 had an amount discrepancy when reconciling all provided transaction documents.

At the request of the Tennessee Valley Authority's (TVA) Supply Chain, we examined the cost proposal submitted by a company for engineering, design, and construction support services. Our examination objective was to determine if the company's cost proposal was fairly stated for a planned 5-year, $45 million contract.In our opinion, the company's cost proposal was overstated. Specifically, we found the (1) proposed costs for the request for proposal's (RFP) example projects contained math errors, were not priced in accordance with the RFP requirements, and overstated travel expenses; (2) proposed total labor markup rate, for recovery of the company's indirect costs, was overstated compared to recent actual costs; (3) proposal did not include reduced labor markup rates for employees working in the field and nonbenefited workers; and <br> (4) proposed maximum wage rates were overstated.We estimated TVA could avoid about $3.08 million over the planned $45 million contract by (1) ensuring the company's project estimates and invoices are reviewed for accuracy and comply with contract pricing criteria, (2) negotiating a reduced total labor markup rate based on the company's recent actual costs, (3) including labor markup rates for employees performing work in the field and nonbenefited workers, and (4) requiring the company to revise its wage range maximums.(Summary Only)

The VA Office of Inspector General (OIG) conducted an inspection to evaluate facility oversight and leaders’ response to a pathologist’s practice at the facility. The OIG found the Pathology and Laboratory Medicine Chief (Chief) followed VHA policy and performed a quality review of surgical pathology cases and reported the pathologist’s initial misdiagnosis. Facility leaders ensured the required comprehensive clinical care reviews were conducted, resulting in the discovery of 10 additional misdiagnoses. The pathologist also misdiagnosed a skin biopsy. The Chief followed Veterans Health Administration (VHA) policy for secondary reviews of the misdiagnoses, completed supplemental reports, and documented provider notification. The OIG found no documentation that providers informed three patients of their misdiagnoses. The OIG learned one patient experienced an adverse clinical outcome and did not have any documented disclosures. Also, facility staff and leaders did not report any of the misdiagnoses as adverse events. Facility leaders summarily suspended the pathologist; however, the OIG found no documentation renewing the suspension. The Facility Director then terminated the pathologist. The pathologist appealed the termination through the VHA Disciplinary Appeals Board, which recommended a reinstatement. The pathologist was reinstated, and clinical privileges were restored. Facility leaders did not comply with VHA’s mandated privileging processes and were unaware of who was responsible for state licensing board reporting. Quarterly retrospective reviews of all pathology reports exceeded the 10 percent standard; however, the Chief and staff pathologists did not consistently review 10 percent of each pathologist’s cases. The Chief and staff pathologists reviewed 9.4 percent of the pathologist’s cases, below the 10 percent requirement. The OIG made 10 recommendations related to test results, disclosure and reporting of adverse events, issue briefs, the summary suspension process, the credentialing and privileging process, state licensing board reporting, and quality reviews of the pathologists’ work.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Illiana Health Care System and multiple outpatient clinics in Illinois. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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 positions were filled more than six months prior to the on-site visit. Survey results revealed opportunities for the Associate Director to improve employee satisfaction and for the Chief of Staff and Associate Director Patient Care Services to improve staff feelings of “moral distress” at work. Patient experience survey data indicated that patients appeared satisfied with their care. The OIG’s review of the system’s accreditation findings did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scopes of responsibilities about selected Strategic Analytics for Improvement and Learning data and should continue to take action to sustain and improve performance.

This report presents the results of our audit of all stamp and cash inventories at six postal units in Chicago, IL. These offices were located in the Chicago District of the Great Lakes Area. We conducted this audit in response to concerns raised by the U.S. Postal Inspection Service of potentially lost stamps, cash, and money orders due to looting of offices during protests and riots from May 29 through June 1, 2020. The six postal units audited were Englewood, Station K, Wicker Park Retail Store, Wicker Park Carrier Annex, Ogden Park, and Henry W. McGee. All six postal units had thefts of mail and parcels. One unit had theft of stamps and cash. One unit did not have any stamp or cash inventory.

Our objective was to evaluate the performance of the U.S. Postal Service’s Small Package Sorting System (SPSS) machines.The continued growth of eCommerce and the package delivery market provides opportunities for the Postal Service to increase revenue. The Postal Service has directed resources and management attention toward building a world-class package platform to compete and gain business in the package delivery market. Part of this strategy includes purchasing package processing machines such as the SPSS to improve efficiency and meet demand.

Congress has expressed concerns about the safety and well-being of children in foster care. Additionally, in a recent series of audits of State-monitored child care facilities in various States, we found that the majority of child care providers had instances of potentially hazardous conditions and noncompliance with State health and safety requirements, including employee background record check requirements. To determine whether similar vulnerabilities exist in foster care group homes, we performed this audit in Kansas. Allegations of neglect and abuse at some foster care group homes in Kansas were the subject of a number of reports in the media, both before and during our audit.

The OIG investigated allegations that a U.S. Bureau of Reclamation (BOR) project management specialist illegally diverted water from a BOR canal to a private ranch. Our investigation confirmed the project management specialist approved the water diversion, but we did not find evidence the project management specialist received any personal benefit, financial or otherwise, as a result. The project management specialist said they approved the water diversion because they were trying to solve the ranch owner’s concern that construction in the area had blocked flood-water overflow from coming onto the ranch owner’s property. The project management specialist further said they were concerned that the ranch owner would terminate an agreement that allowed the BOR to operate a pump station—which the BOR uses to protect endangered species in the area by pumping water to dry areas—on the ranch owner’s property because the terms of the agreement allowed the ranch owner to terminate the agreement if the ranch owner believed the BOR impeded any of their projects.We further found the project management specialist circumvented engineering and environmental approval by funding the project through an existing operations and maintenance contract instead of a new contract, which would have triggered the BOR’s review and approval process. The project management specialist said they believed the project was within the scope of work of the existing contract and did not seek approval before authorizing the water diversion.

What We Looked AtThe National Airspace System (NAS) serves over 44,000 flights a day with over 5,000 aircraft in the sky at peak times. Critical to the NAS's operations are the Federal Aviation Administration's (FAA) 20 Air Route Traffic Control Centers (Centers) that manage high-altitude air traffic. These Centers are equipped with the En Route Automation Modernization (ERAM) system to manage and control high-altitude operations and provide infrastructure for new systems such as high-altitude data link communications for FAA's Next Generation Air Transportation System (NextGen). In response to requests from the Senate Committee on Commerce, Science, and Transportation and the House Committee on Transportation and Infrastructure and its Aviation Subcommittee, we conducted this audit. Our objectives were to (1) evaluate FAA's planned upgrades to ERAM and (2) assess ERAM's ability to support key NextGen capabilities.What We FoundFAA is making a significant investment to sustain and enhance ERAM's hardware and software at the Centers. Over 6 years, the Agency will replace ERAM's original computer hardware and modernize ERAM's software to allow system improvements and new capabilities. Once these upgrades are complete, ERAM will essentially be a new system with enhanced capabilities. FAA plans to continue to add capabilities and keep the system up to date. FAA has re-categorized ERAM from a moderate to a high-impact system but has not yet determined what security controls the system will require as a high-impact system.FAA has integrated NextGen capabilities into ERAM but faces challenges realizing full benefits for airspace users. FAA considers ERAM foundational to many NextGen systems, including the Automatic Dependent Surveillance--Broadcast (ADS-B) system, performance based navigation (PBN), and data communications (DataComm). The Agency has integrated ADS-B and PBN with ERAM but has encountered delays implementing DataComm's high-altitude services due to the impact of the Federal Government shutdown in late 2018 and early 2019, air-to-ground network problems, and other issues. Because FAA will develop new procedures and training for controllers and pilots for these capabilities, it is uncertain when these enhancements and NextGen capabilities will provide full benefits for airspace users.RecommendationsWe made one recommendation to help FAA improve its efforts to upgrade ERAM to support NextGen capabilities. FAA concurred with our recommendation.

This audit report is one of a series of OIG reports addressing the identification, reporting, and investigation of incidents of potential abuse or neglect of our Nation's most vulnerable populations, including the elderly and individuals with developmental disabilities. Our objectives were to determine whether North Carolina (1) ensured that nursing facilities reported potential abuse or neglect of Medicaid beneficiaries transferred from nursing facilities to hospital emergency departments; (2) complied with Federal and State requirements for assigning a priority level, investigating, and recording allegations of potential abuse and neglect; and (3) operated its complaint and incident report program effectively.

o U.S. Customs and Border Protection (CBP) does not comprehensively plan and conduct its covert testing, use test results to address vulnerability, or widely share lessons learned. CBP’s two covert testing groups do not use risk assessments or intelligence to plan and conduct covert tests at ports of entry and U.S. Border Patrol checkpoints, do not plan coordinated tests, and do not design system-wide tests. This occurred because CBP has not provided adequate guidance on risk- and intelligence-based test planning, directed the groups to coordinate, given them the required authority, or established performance goals and measures for covert testing. Following testing, CBP does not widely share covert test results, consistently make recommendations, or ensure corrective actions are taken. Results are not widely shared because CBP has not defined roles and responsibilities for such sharing. Covert testing groups do not make recommendations or ensure corrective actions are implemented due to insufficient authority and policies directing these actions. Finally, CBP does not effectively manage covert testing groups to ensure data reliability, completeness, and compliance with security requirements due to leadership changes and limited staff. Without comprehensive planning, incorporating lessons learned from test results, and program management accountability, CBP cannot ensure it addresses vulnerabilities, which may be exploited and threaten national security. We recommended CBP develop policies and procedures for conducting covert testing and assign roles and responsibilities for oversight of covert testing groups. We made seven recommendations that will strengthen its covert testing program. CBP concurred with all seven recommendations.

The Office of Special Reviews investigated allegations that a GS-14 employee in VA’s Office of Information and Technology misused his government email by sending personal emails during work hours, and also took advantage of his telework arrangement to handle personal matters during his duty hours. The OIG could not substantiate the misuse of official time or improper use of VA resources because the employee routinely worked outside of his regular duty hours with his supervisor’s approval, and VA has not established criteria defining how much personal use of VA email is excessive. While investigating these issues, the OIG became aware that the employee had referred staff who were planning conferences for his group to his wife, a sales manager for a large hotel chain, and sent emails providing direction about the arrangements for these conferences. The staff subsequently booked rooms for these events at hotels for which the employee’s wife had sales responsibility. Although the staff made the decision and the arrangements were advantageous to VA, the OIG determined that the employee’s conduct appeared contrary to ethical rules prohibiting an employee from using his public office for “his own private gain, for the endorsement of any product, service or enterprise, or for the private gain of friends, relatives, or persons with whom the employee is affiliated in a nongovernmental capacity….” The OIG made one recommendation relating to a supervisory review of the employee’s conduct and consideration of appropriate administrative action, if any. VA concurred with this recommendation.

Following the death of a Peace Corps/Ghana Volunteer, we conducted a review to assess the sufficiency of Volunteer training and Volunteer housing procedures to mitigate the risk of future accidents involving gas tanks used for cooking. Our report contains 4 recommendations to improve the agency's actions regarding gas cooking safety.

The VA Office of Inspector General (OIG) investigated a non-specific allegation that chief nurses within the Miami VA Health Care System (Miami HCS) violated the federal anti-nepotism statute by arranging to have their spouses hired for positions for which the spouses were not qualified. This allegation could not be substantiated. In addition, a specific allegation of nepotism was made pertaining to the conduct of a particular chief nurse. The OIG substantiated the allegation that the chief nurse violated the anti-nepotism statute by recommending the chief nurse’s spouse for a position at the Miami HCS. The chief nurse falls under the statutory definition of a public official and was prohibited from advocating for the employment by VA of the chief nurse’s spouse. The chief nurse was involved in two communications relating to the spouse’s possible employment at VA, one of which the OIG considered advocacy contrary to the federal anti-nepotism statute. The spouse withdrew his/her application without providing an explanation and was not hired by VA. The OIG made one recommendation relating to administrative action against the chief nurse if the Miami HCS Director deems it appropriate. VA concurred with the OIG’s finding and determined administrative action at this time is unwarranted. The OIG considers the recommendation closed.

The VA Office of Inspector General (OIG) conducted an inspection at the Washington DC VA Medical Center (facility) to assess care provided to a patient six days prior to death by suicide and an allegation that an Emergency Department physician made a statement to the effect of “[the patient] can go shoot [themself]. I do not care.” The OIG substantiated that the patient died by suicide six days after presenting to the Emergency Department with suicidal ideation and staff failed to complete required suicide prevention planning. During the 12-hour episode of care, the patient navigated two transitions between the Emergency Department and outpatient Mental Health Clinic and saw seven providers. Lack of collaboration between providers, hand-off process deficiencies, and providers’ failure to read the outpatient psychiatrist’s notes led to a compromised understanding of the patient’s medical needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan. The OIG substantiated that an Emergency Department physician made a statement to the effect of “[the patient] can go shoot [themself]. I do not care,” which could be considered misconduct and patient abuse. Facility and contracted staff failed to report the behavior and did not receive required annual abuse and neglect policy education. The Emergency Department physician had a history of verbal misconduct. Despite facility leaders’ awareness by late spring 2019 of physician 2’s inappropriate statement regarding the patient and physician 2’s prior pattern of misconduct, facility leaders did not conduct a formal fact-finding or administrative investigation as required by VA. The Suicide Prevention Coordinator failed to complete the required suicide behavior report and the Emergency Department did not meet Veteran Health Administration’s requirements for a safe and secure mental health evaluation area. The OIG made one recommendation to the Veterans Integrated Service Network Director and 10 recommendations to the Facility Director.

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 Bureau of Indian Education in June.This report presents the DOI’s progress as of June 30, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $393,538,262 and its obligations total $534,545,127.We are also monitoring the DOI’s progress on reporting milestones established by the CARES Act and the Office of Management and Budget.We anticipate issuing updated status reports monthly.

The Puerto Rico Electric Power Authority (PREPA) complied with Federal procurement requirements for its noncompetitive procurement of the Whitefish contract. However, the contract costs may not have complied with Federal cost principles that costs must be reasonable to be eligible for Federal awards. PREPA’s oversight of the Cobra contract did not comply with PA program guidelines. Finally, FEMA’s Public Assistance grant to PREPA for the Cobra contract did not fully comply with PA program guidelines. We made two recommendations for FEMA to provide technical assistance to Puerto Rico to ensure compliance with Federal regulations and PA program guidelines. We made two other recommendations for FEMA to develop guidance to verify its subrecipients’ oversight of time and material contracts and determine the reasonableness and eligibility of time and material contract costs. FEMA concurred with three of the recommendations and did not concur with one recommendation.

New York pays managed care organizations (MCOs) to make services available to enrolled Medicaid beneficiaries in return for a monthly fixed payment for each enrolled beneficiary (capitation payments). The New York Medicaid Assistance Program (New York Medicaid) is the second largest Medicaid program in the Nation. New York Medicaid provides health coverage to almost 6.2 million of New York's residents. Approximately 80 percent of the New York Medicaid population is enrolled in managed care.

Our objective is to inform the Postal Service of significant vulnerabilities associated with applications developed and maintained under this contract that did not complete the Certification and Accreditation (C&A) process.

Our objective was to assess the effectiveness of the internal communication and implementation of Informed Delivery sign up at retail facilities. Informed Delivery is the U.S. Postal Service’s offering that allows customers to digitally preview their letter mail and package delivery via email notifications, online dashboard, or mobile application. Our fieldwork was completed before the President of the United States issued the national emergency declaration concerning the novel coronavirus disease outbreak on March 13, 2020. The results of this audit do not reflect operational changes or service impacts that may have occurred throughout the Postal Service’s operational network as a result of the pandemic.

The Office of Inspector General is issuing this management alert to the U.S. AbilityOne Commission (Commission) as notice that the Agency’s ability to mitigate risk in its programs and operations remains inadequate. Senior Agency staff has failed to address internal controls, and noncompliance with Office of Management and Budget (OMB) revised Circular A-123, Management’s Responsibility for Enterprise Risk Management and Internal Control, persists.

The Child Care and Development Block Grant Act (CCDBG Act) of 2014 added new requirements for States receiving funding from the Child Care and Development Fund (CCDF) to conduct comprehensive criminal background checks on staff members and prospective staff members of child care providers every 5 years. Criminal background check requirements apply to any staff member who is employed by a child care provider for compensation or whose activities involve the care or supervision of children or unsupervised access to children.

We reviewed the oversight of opioid prescribing and the monitoring of opioid use in Ohio. This factsheet shows Ohio's responses to our questionnaire covering five categories related to its approach to addressing the opioid epidemic: policies and procedures, data analytics, programs, outreach, and other efforts.