Federal Reports

Please see the link below for a podcast discussing the results of this review.

OIG conducted this audit at the request of Congressman Mike Coffman in response to an allegation that the South Texas Veterans Health Care System (STVHCS) had about 20,000 past due pending radiology orders. To address the allegation, OIG evaluated if STVHCS had past due radiology orders that required action and adversely affected patients’ quality of care. OIG substantiated the allegation that STVHCS Imaging Service had a significant number of past due radiology orders, although fewer than alleged by the complainant. OIG identified 17,790 potentially past due pending orders with a clinically indicated date before January 1, 2016. OIG projected that as of January 5, 2016, STVHCS had 5,500 patients with 7,200 pending past due orders that were not completed or not scheduled for timely completion. Additionally, OIG estimated STVHCS had as many as 9,500 pending orders that should have been canceled. This occurred because STVHCS Imaging Service lacked an effective manual hard copy radiology exam scheduling process, a means of ensuring pending orders were canceled when no longer needed, and procedures to address delays and prevent duplicate orders. The STVHCS Imaging Service’s inability to provide patients with timely radiological care adversely affected the quality of care provided to some patients. The Office of Healthcare Inspection’s clinical reviews confirmed that delays had minor clinical impacts on 14 patients and an intermediate clinical impact on one patient. OIG recommended the STVHCS Director address STVHCS’s current pending radiology order inventory and strengthen radiology exam scheduling, management, and monitoring controls to prevent future delayed exams. In response to this audit, STVHCS reported it had reduced its pending radiology inventory to only 366 orders as of April 19, 2017. The STVHCS Director concurred with OIG's recommendations and provided an action plan to address these recommendations. OIG will monitor the planned actions and follow up on implementation.

OIG conducted a healthcare inspection to assess allegations regarding pressure ulcer prevention and management at the Brooklyn and Manhattan campuses of the VA New York Harbor Healthcare System (system), New York, NY. The timeline of events and allegations were: in 2014, a patient developed pressure ulcers following admission to the system, which were not appropriately managed by clinical staff. Initially, OIG’s Hotline Division requested that the system conduct a review of the complainant’s allegations and submit a response. We determined the response to be insufficient. We subsequently referred the matter to the Veterans Integrated Service Network (VISN) for a response and included specific questions for VISN leadership to address. In 2015, another patient developed pressure ulcers, which were not appropriately managed by clinical staff. In April 2016, we determined the second response regarding Patient A was insufficient and after reviewing a similar complaint from Patient B, we initiated this healthcare inspection. We substantiated that Patient A developed pressure ulcers that subsequently worsened following admission, and clinical staff failed to implement timely and appropriate interventions. We substantiated that Patient B developed pressure ulcers following admission. However, we found that clinical staff timely identified and took steps to address Patient B’s pressure ulcer, which healed prior to his initial discharge from the system. We noted that clinical staff skin care documentation was incomplete and inconsistent for both Patients A and B. To further evaluate the system’s quality of pressure ulcer documentation, we reviewed electronic health records of acute care patients with pressure ulcers who were discharged from December 1, 2015 through May 31, 2016, and January 2017. We identified noncompliance with requirements for pressure ulcer prevention and management-related documentation. Since the time of our onsite visit in late June 2016, some issues with the quality of pressure ulcer documentation persisted.

In early 2017, OIG evaluated the Phoenix VA Regional Office (VARO) to see how Veterans Service Center (VSC) staff processed disability claims, timely and accurately processed proposed rating reductions, input claim information, and responded to special controlled correspondence. Staff didn't consistently process one of the two types of disability claims. OIG reviewed 30 veterans’ traumatic brain injury claims and found staff accurately processed 29 of 30 claims. OIG reviewed 30 special monthly compensation (SMC) benefits claims and found that Rating Veterans Service Representatives incorrectly processed 3 of 30 claims due to a lack of effective oversight. Overall, VSC staff correctly processed 56 of the 60 disability claims OIG reviewed; however, the errors resulted in 73 improper payments to 3 veterans totaling approximately $44,700. OIG reviewed 30 rating reductions cases and found that staff delayed or incorrectly processed 11 cases—resulting in approximately $15,500 in overpayments and $2,400 in underpayments. This was due to prioritization of other workloads. OIG reviewed 30 newly established claims and found staff didn't correctly input claim and claimant information into the electronic systems for 15 claims due to ineffective operational oversight. OIG reviewed 30 special controlled correspondences, finding inaccuracies in 11 cases because of a lack of training and outdated local guidance. Specifically, in nine of the cases, congressional liaisons didn’t upload all of the required documents, such as privacy consent documents, congressional inquiries, or final responses to the veterans’ electronic claims folders. Therefore, Veterans Benefits Administration management and staff would not be able to review issues pertaining to timeliness and accuracy of these documents in the veterans’ electronic claims folders. OIG recommended the Phoenix VARO Director implement plans to improve oversight of SMC decisions; place higher priority on rating reductions; ensure data entered at the time of claims establishment are accurate; and provide training for special controlled correspondence processing. The Director concurred with our recommendations and the planned corrective actions are responsive.

OIG conducted an inspection to evaluate the merit of a concern submitted by the Drug Enforcement Administration (DEA) regarding the Marion Division of the VA Northern Indiana Health Care System (VANIHCS). The DEA reported a large opioid purchase increase by VANIHCS, Marion Division in fiscal year (FY) 2015 when compared to FY 2014 and to local Marion non-VA hospitals. We suspended our inspection. We decided to suspend the review because the Marion Division pharmacy purchases medications for patients in the Marion catchment area and for VANIHCS’s four community based outpatient clinics, and we determined that comparing the Marion Division pharmacy purchases to a local hospital’s pharmacy purchases was not an equal comparison to the population size or type served. Additionally, regulatory changes occurred in October 2014 that re-categorized hydrocodone from a Schedule III to a Schedule II drug that required the Marion Division pharmacy to begin purchasing and dispensing hydrocodone, which patients had previously obtained via mail order from a Consolidated Mail Outpatient Pharmacy. Therefore, it would be expected that the Marion Division pharmacy would be purchasing and dispensing larger numbers of opioid medications. The DEA did not have evidence of specific patient harm regarding opioid prescribing practices at the Marion Division, and our preliminary onsite interviews at the Marion Division did not reveal evidence of patient harm or drug diversion. We suspended our inspection after determining there was a rationale for the increase in purchases of hydrocodone at the Marion Division. We made no recommendations.

EAC OIG, through an interagency agreement with the U.S. Postal Service OIG, conducted this audit to determine whether EAC's decision-making controls were properly designed, placed in operation, and operating effectively to provide reasonable assurance that key EAC decision-making policies met their objectives.

Kentucky did not always determine Medicaid eligibility in accordance with Federal and State requirements. For our sample of 120 beneficiaries, Kentucky correctly determined eligibility for 113 beneficiaries, but it did not meet Federal and State requirements for eligibility determinations of 7 beneficiaries. Specifically, Kentucky did not always maintain documentation supporting that it electronically or manually verified citizenship. In addition, although it did not violate an eligibility requirement, Kentucky did not perform or did not maintain documentation that it had performed identity-proofing for 13 beneficiaries in accordance with Federal requirements. The Federal identity-proofing requirements are intended to reduce the potential for identity theft.

OIG conducted a healthcare inspection in response to allegations from anonymous complainant(s) regarding the quality of care provided by a thoracic surgeon at the Bay Pines VA Healthcare System (system), Bay Pines, FL. We did not substantiate that the thoracic surgeon was incompetent. However, we identified a deficiency in the system’s process for evaluating surgeons’ competency. Contrary to VA policy, the criteria used in focused professional practice evaluations (FPPE) were not privilege-specific and inadequate to fully assess a provider’s skills. An August 2016 Deputy Under Secretary for Health for Operations and Management memorandum specified that as of August 2017, a provider with similar training and privileges should conduct ongoing professional practice evaluations (OPPE). The surgeon’s OPPE that we reviewed had been completed prior to the August 2016 DUSHOM memorandum and was done by an administrative psychiatrist.We did not substantiate that the surgeon had a high rate of complications. We did not identify specific quality of care concerns in the surgeon’s mortality cases we reviewed. The anonymous complainant(s) provided nine specific patient cases. We consulted with a thoracic surgeon who did not identify quality of care concerns for the nine patients. We also identified six deaths occurring within 30 days of a thoracic surgical procedure. We did not identify quality of care concerns with these cases. We substantiated that the thoracic surgeon requested the critical care team not care for his patients related to disagreements about fluid management. We determined that he had the authority to do so under the system’s policy.We could not substantiate that surgeons left the system because of quality of care concerns related to the thoracic surgeon, or that the Chief of Staff and/or System Director were aware of concerns regarding the thoracic surgeon’s competence yet failed to address them. We made two recommendations.

HHS oversees States' administration of various Federal programs, including Medicaid. State agencies are required to establish appropriate computer system security requirements and conduct biennial reviews of computer system security used in the administration of State plans for Medicaid and other Federal entitlement benefits. This review is one of a number of HHS OIG reviews of States' computer systems used to administer HHS-funded programs. Our objective was to determine whether the North Carolina had implemented adequate information system general controls over the North Carolina Medicaid claims processing systems in accordance with Federal requirements.

NARA OIG performed this audit to assess the current status of the ERA 2.0 development effort.

The Office of the Inspector General audited Tennessee Valley Authority (TVA) Internet-accessible Web sites to identify cyber security weaknesses through penetration testing. In summary, 37 Internet-accessible Web sites were tested, and 7 high risk vulnerabilities were identified. Two of the high risk vulnerabilities that were identified require additional testing by TVA's Information Technology for confirmation. TVA management agreed with our findings and recommendations.

The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the James E. Van Zandt VA Medical Center. This included reviews of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Community Nursing Home (CNH) Oversight; Management of Disruptive/Violent Behavior; and Post-Traumatic Stress Disorder Care. OIG provided crime awareness briefings to 50 employees.OIG identified certain system weaknesses in taking actions for issues identified by quality, safety, and value reviews; medical staff membership; general safety and security of personally identifiable information at the Huntingdon County VA Clinic; the anticoagulation management program; inter-facility transfer data collection and reporting; point-of-care testing follow-up; CNH oversight and clinical visits; and disruptive behavior training. As a result of the findings, OIG could not gain reasonable assurance that: (1) The facility takes actions for weaknesses identified in peer review and Focused Professional Practice Evaluations.(2) Facility leadership is able to perform appropriate oversight of all medical staff members.(3) The access log for the Huntingdon County VA Clinic information technology network room contains required elements.(4) The Huntingdon County VA Clinic secures patients’ personally identifiable information.(5) A physician is involved in the anticoagulation management program.(6) Data is used to improve inter-facility transfers.(7) Clinicians document required actions in response to glucose point-of-care testing results.(8) The facility effectively oversees the CNH program and monitors and assures the safe care of patients in the program.(9) Facility employees are trained to reduce and prevent disruptive behaviors.OIG made recommendations for improvement in the following seven areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Coordination of Care; (5) Diagnostic Care; (6) CNH Oversight; and (7) Management of Disruptive/Violent Behavior.

The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the VA Northern Indiana Health Care System. This included reviews of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. OIG provided crime awareness briefings to 53 employees.OIG identified certain system weaknesses in utilization management; environmental cleanliness; anticoagulation processes and competency assessment; transfer data collection and documentation; re-evaluations prior to moderate sedation procedures; community nursing home clinical visits; disruptive behavior program implementation, processes, and training; and credentialing and privileging. As a result of the findings, OIG could not gain reasonable assurance that: (1) Physician advisors provide input for utilization management decisions.(2) The facility maintains clean bed frames.(3) The facility has a comprehensive anticoagulation therapy management program.(4) The facility has effective processes for the safe transfer of patients.(5) Clinicians re-evaluate patients prior to moderate sedation procedures.(6) The facility monitors and assures the safe care of patients in the community nursing home program by conducting clinical visits.(7) The facility effectively manages disruptive/violent behavior incidents, and employees receive training to reduce and prevent disruptive behaviors.(8) The facility has an effective process for approving another facility’s physicians for teledermatology services and obtaining professional practice evaluation data for telemedicine providers.OIG made recommendations for improvement in the following seven review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Coordination of Care; (5) Moderate Sedation; (6) Community Nursing Home Oversight; and (7) Management of Disruptive/Violent Behavior. OIG made repeat recommendations from the previous Combined Assessment Program review in Quality Management.

The Federal Managers’ Financial Integrity Act (FMFIA), P.L. 97-255, as well as the Office of Management and Budget’s (OMB) Circular A-123, Management Accountability and Control, establish specific requirements for management controls. Each agency head must establish controls to reasonably ensure that: (1) obligations and costs are in compliance with applicable laws; (2) funds, property and other assets are safeguarded against waste, loss, unauthorized use, or misappropriation; and (3) revenues and expenditures applicable to agency operations are properly recorded and accounted for in order to permit the preparation of reliable financial and statistical reports, as well as to maintain accountability over the assets. FMFIA further requires each executive agency head, on the basis of an evaluation conducted in accordance with applicable guidelines, to prepare and submit a signed statement to the President disclosing that the agency’s system of internal accounting and administrative control fully comply with requirements established in FMFIA.

OIG conducted a healthcare inspection to follow up on concerns regarding access to care in the urology service at the Phoenix VA Health Care System (system) in Phoenix, Arizona. We limited our inspection to determining whether a delay in care was associated with adverse patient impact.During OIG’s 2014 review of system scheduling practices and wait times, we reported that large numbers of patients referred for urological evaluation and/or treatment experienced significant delays. The delays involved obtaining an appointment, scheduling follow-up, and/or receiving authorizations for non-VA urology care (see: Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System, Phoenix, Arizona; [Report No. 14-02603-267, August 26, 2014]). OIG’s Office of Healthcare Inspections opened an expanded review focusing on access to urology care at the system. An interim report Review of Phoenix VA Health Care System’s Urology Department Phoenix, Arizona; (Report No. 14-00875-112, January 28, 2015), detailed our findings regarding incomplete documentation for 759 urology patients and the potential impact on care. In Review of Access to Urology Service at the Phoenix VA Health Care System, Phoenix, Arizona; (Report No. 14-00875-03, October 15, 2015), we found a significant urology staffing shortage, inconsistent non-VA urology provider documentation of patient care, and untimely care to patients needing urological services. We committed to reviewing the records and management of the 759 patients once the Veterans Health Administration provided us with the necessary documentation. This report details these findings. We determined that 148 (20 percent) of the 759 patients experienced delays in getting new evaluations or follow-up appointments. When a delay was identified, we assessed the impact of that delay on the patient’s care. From a clinical standpoint, we found that none of the patients were adversely impacted by a delay in care.

OIG conducted a healthcare inspection to assess whether safety screenings were performed and documented prior to magnetic resonance imaging (MRI) at the Central Alabama Veterans Health Care System (system), Montgomery, AL. The system has an agreement with a Department of Defense clinic, Lyster Army Health Clinic (Lyster), for MRI services. Lyster staff do not have access to VA electronic health records (EHRs) and system staff do not have access to Lyster EHRs. A powerful magnetic field around MRI scanners creates safety risks. Safety screening is critical to alert staff of patients’ electronic, mechanical, or magnetic implants. VHA requires pre-MRI initial and secondary safety screenings. We did not find a VHA or system policy addressing documentation requirements of MRI safety screening forms completed at non-VA facilities. We reviewed 158 of 2,753 MRI orders (6 percent) completed at the system or at Lyster from September 22, 2014 through September 22, 2015, to assess documentation of initial and secondary safety screenings. In September 2015, the system took steps to ensure that staff completed initial safety screening forms when the MRI was ordered for patients receiving MRIs at Lyster. We found 17 patients who received MRIs at Lyster without initial safety screenings. However, Lyster staff had completed and documented the secondary safety screenings in the Lyster EHRs, and completed the MRIs. We reviewed the 158 patients for secondary screenings. Secondary safety screening forms were not available in VHA EHRs but were in the Lyster EHRs; copies of the completed forms would be made available upon request. To evaluate safety screening documentation after September 2015, we reviewed 50 of 475 MRI orders (10.5 percent) placed in July 2016. Ten of the 50 were excluded. We found that the remaining MRI orders included the initial safety screening in the VHA EHR.

OIG evaluated controls over the health care enrollment program administered at VA medical facilities and determined if enrollment actions were processed timely and supported by required documentation. OIG found that VHA did not provide effective governance necessary to ensure oversight and control over the health care enrollment program medical facilities. Specifically, VHA required medical facilities to establish procedures for processing enrollment applications without implementing effective processes to monitor those activities. Only 38 of 106 VA medical facilities sampled had local enrollment policies. Medical facilities that did have guidance were permitted to adopt practices that were inconsistent with national policies. Conflicts between local practices and national policies occurred because VHA lacked appropriate guidance, oversight, and monitoring to ensure a standardized enrollment process. Formal training was also not provided to eligibility and enrollment staff at VA medical facilities. OIG also found that data systems did not have the capability to identify new enrollment applications or provide the basis for independent testing of timeliness or supporting documentation. Based on a statistical sample, OIG projected that only 197,000 of 427,000 enrollment records in the universe represented FY 2015 applications for enrollment. Further, OIG could not make conclusions related to timeliness or supporting documentation. This occurred because VHA did not adequately monitor program effectiveness or ensure that accurate data were available for program transparency. OIG recommended VHA develop standardized national policy and procedures, implement national oversight, and provide mandatory and standardized training for the health care enrollment program at VA medical facilities. OIG also recommended VHA implement a plan to correct the data integrity issues necessary to improve the accuracy and timeliness of health care enrollment data.

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

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

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

Not all of the direct medical service costs that the Texas Health and Human Services Commission (State agency) claimed for Medicaid School Health and Related Services (SHARS) were reasonable, adequately supported, and otherwise allowable in accordance with applicable Federal and State requirements. Specifically, Fairbanks, LLC (the Contractor), coded random moments incorrectly. Of the 3,161 random moments coded as an Individualized Education Plan-covered direct medical service, 274 were coded incorrectly. As a result of these errors, the State agency received $18.9 million in unallowable Federal reimbursement for the Medicaid SHARS program during the period October 1, 2010, through September 30, 2011.

The Office of the Inspector General previously conducted an evaluation of Bull Run Fossil Plant (BRF) (Evaluation Report 2015-15357 issued March 30, 2016) to identify strengths and risks that could impact BRF's organizational effectiveness. Our final report identified several operational and cultural areas for improvement along with recommendations for addressing those issues. The objective of this follow-up evaluation was to assess management's actions in response to our recommendations from our initial organizational effectiveness evaluation. In summary, we determined the actions taken by BRF appear to address most areas for improvement identified during our initial organizational effectiveness evaluation, and for the most part, individuals reported seeing positive changes at BRF. Some concerns remain related to specific areas in the work management process, including planning of work and communication of work order and condition report statuses. However, resolution of these concerns relies on funding decisions that are generally outside of BRF's control.

The Department of Homeland Security made progress in implementing the JTFs since their inception in 2014. According to JTF leaders, operational effectiveness and efficiency has increased; staff morale has improved; and components have successfully worked together to promote information sharing and communication.Although the JTFs are a step forward for DHS, they face challenges, including a need for dedicated funding and outcome-based performance measures. Without dedicated funding, the JTFs rely on components that may have competing or conflicting priorities. Without performance metrics, the JTFs cannot show the value they add to homeland security operations.The Department of Homeland Security made progress in implementing the JTFs since their inception in 2014. According to JTF leaders, operational effectiveness and efficiency has increased; staff morale has improved; and components have successfully worked together to promote information sharing and communication.Although the JTFs are a step forward for DHS, they face challenges, including a need for dedicated funding and outcome-based performance measures. Without dedicated funding, the JTFs rely on components that may have competing or conflicting priorities. Without performance metrics, the JTFs cannot show the value they add to homeland security operations.We made no recommendations.

In October 2016, OIG evaluated the New Orleans VARO to see how VSC staff processed disability claims, timely and accurately processed proposed rating reductions, input claim information, and responded to special controlled correspondence. Staff did not consistently process one of the two types of disability claims we reviewed. OIG reviewed 30 veterans’ TBI claims and found staff accurately processed all 30 claims. OIG reviewed 30 SMC benefits claims and found VSC staff incorrectly processed four claims because second signature reviews were ineffective. The four claims with errors had the required secondary reviews; however, the reviewers did not identify the errors. Overall, VSC staff accurately processed 56 of the 60 disability claims OIG reviewed—the four errors resulted in 25 improper payments to four veterans totaling approximately $25,500. OIG reviewed 30 rating reductions cases and found VSC staff delayed or incorrectly processed six of the cases. Delays occurred because VSC managers prioritized other workload. Delays and inaccuracies resulted in eight improper payments, representing approximately $2,800 in overpayments. OIG reviewed 30 newly established claims and found VSC staff entered inaccurate or incomplete information into the electronic systems in 21 of 30 claims because VSC staff did not complete all required training related to establishing claims, and the quality review process for this function was ineffective. OIG reviewed 30 special controlled correspondences, finding inaccuracies in 21 cases because management was unaware that staff did not follow VBA policy when processing the correspondence. Specifically, staff did not send interim responses when required or ensure consent to release records to third parties were of record prior to releasing records. Staff also used incorrect dates to establish workload controls and did not associate the correspondence with the electronic record as required. In addition, errors occurred because training for staff on processing controlled correspondence did not exist. OIG recommended the New Orleans VARO Director assess the effectiveness of secondary reviews for SMC claims; train VSC staff responsible for establishing claims to do so using accurate and complete information; and strengthen the quality review over the course of this process. The VARO Director should ensure staff comply with VBA policy when processing special controlled correspondence and ensure they are trained in processing this workload. Additionally, OIG recommended the Continental District Director ensure the timely processing of the rating reduction workload. The VARO Director and Continental District Director concurred with our recommendations; planned corrective actions are responsive.

In December 2016, we evaluated the Atlanta, Georgia, VARO to determine how well staff processed disability claims, how timely and accurately they processed proposed rating reductions, how accurately they entered claims-related information, and how well they responded to special controlled correspondence.VSC staff did not consistently process one of the two types of disability claims we examined. We reviewed 30 of 1,590 veterans’ traumatic brain injury claims and found RVSRs accurately processed 27 cases. However, RVSRs did not always process entitlement to SMC and ancillary benefits consistent with VBA policy. We reviewed 30 of 67 special SMC claims and found RVSRs inaccurately processed four cases due to lack of experience evaluating these cases and ineffective oversight for higher-level SMC cases—resulting in 61 improper monthly payments of approximately $27,600. Staff generally processed proposed rating reductions accurately but needed better oversight to ensure timely actions. We reviewed 30 of 733 benefits reduction cases and found staff delayed or inaccurately processed 12 cases. As in our 2014 inspection, staff did not prioritize rating reduction cases. These delays and processing inaccuracies resulted in 101 improper monthly payments to 12 veterans of approximately $41,000.Staff needed to improve the accuracy of claims-related information input into the electronic systems at the time of claims establishment. We reviewed 30 of 3,287 claims. Staff did not correctly input claim information in 12 cases due to incomplete training—which did not provide specific details on associating disabilities with medical classifications—and an insufficient quality review process. Staff needed to improve controls and timeliness for processing special controlled correspondence. We reviewed 30 of 1,170 cases and found staff did not accurately process all 30 due to management’s deviation from VBA policy, as well as lack of adequate oversight. We recommended the VARO Director ensure SMC cases are distributed to the most qualified personnel, monitor the effectiveness of SMC training, ensure accurate signed second-level reviews, provide oversight and prioritization of proposed rating reduction cases, implement a plan to ensure claims assistants receive systems compliance training relevant to claims establishment, and modify the quality review checklist for claims assistants. The Director should ensure that staff properly maintain control of workload and provide timely responses for special controlled correspondence. Management’s planned actions for Recommendations 1-5, 7, and 8 are responsive; however, the Director’s response did not fully address Recommendation 6. We will follow up and continue to assess compliance with VBA policy.

In November 2015, the VA Office of Inspector General (OIG) received an anonymous Hotline complaint alleging that the VA National Work Queue (NWQ) did not perform in a production environment because VA did not test the system to specification. In addition, the complaint claimed that the Veterans Benefits Management System (VBMS) Release 9.1 deployment prevented the processing of 4,000 disability claims. We did not substantiate that NWQ failed to perform in a production environment. At the time of the allegation, NWQ was still in testing and was not processing claims. Moreover, we noted that seven of eight VA Regional Office (VARO) pilot sites reported that NWQ functionality worked when they first started using it to process disability claims in February 2016. One site reported that claims did not automatically route from NWQ into employee queues on the first day. We determined that VA tested NWQ functionality to specification. We reviewed applicable VBMS development artifacts that supported NWQ functionality to include system deployment requirements, configuration control records, test plans, and test cases. From February through June 2016, we noted that the average time for the actual NWQ claims distributions was one hour and 57 minutes; better than the four hour performance standard. We did not find that NWQ functionality had a negative effect upon disability claims processing. Specifically, we noted that none of the eight pilot sites reported lost disability claims resulting from the NWQ implementation. At the time of the allegation, NWQ was not yet used to process claims. We did not find that VBMS Release 9.1 had a significant adverse effect on claims processing, such as preventing the processing of 4,000 disability claims. Accordingly, we made no recommendations for improvements.

Congress authorized the President's Emergency Plan for AIDS Relief (PEPFAR) to receive $48 billion in funding for the 5-year period beginning October 1, 2008, to assist foreign countries in combating HIV/AIDS, tuberculosis, and malaria. Congress authorized additional funds to be appropriated through 2018.

TrailBlazer Health Enterprises, LLC, claimed $228,000 of unallowable Medicare pension costs on its Incurred Cost Proposals for calendar years 2008 through 2013.

In November 2016, we issued our review of the Peace Corps' Sexual Assault Risk Reduction and Response Program as required by the Kate Puzey Peace Corps Volunteer Protection Act of 2011. As part of this evaluation, we reviewed 138 cases files for sexual assaults reported to the Peace Corps. Upon review of a sample of recently unredacted documents, we were able to verify the accuracy of our original 2016 analysis. This memorandum has been appended to the original 2016 report.

The Office of Inspector General (OIG) initiated a survey of the United States Capitol Police (USCP or Department) Containment Emergency Response Team (CERT). Our objective was to solicit and assess feedback from senior officials related to CERT's operations; thereby identifying areas of concern for future work.

The Maine Department of Health and Human Services (State agency) did not comply with Federal Medicaid waiver and State requirements for reporting and monitoring critical incidents involving Medicaid beneficiaries with developmental disabilities residing in community residences. The State agency did not fulfill many of the participant safeguard assurances it provided to the Centers for Medicare & Medicaid Services in its Medicaid waiver. Specifically, the State agency did not (1) ensure that community-based providers reported all critical incidents to the State agency; (2) ensure that community-based providers conducted administrative reviews of all critical incidents involving serious injuries, dangerous situations, or suicidal acts and submitted their findings within 30 days; (3) report appropriately all restraint usage and rights violations to Disability Rights Maine (DRM); (4) review and analyze data on all critical incidents; (5) investigate and report immediately to the appropriate district attorney's office or to law enforcement all critical incidents involving suspected abuse, neglect, or exploitation; and (6) ensure that community-based providers reported all beneficiary deaths to the State agency appropriately and that the State agency analyzed, investigated, and reported the deaths to law enforcement or Maine's Office of Chief Medical Examiner (OCME).

A Brooklyn chiropractor received at least $672,000 over 2 years for chiropractic services that were not allowable in accordance with Medicare requirements.

This summary report provides an overview of the results of our audit of the information system general controls over the New Mexico Medicaid eligibility systems. It does not include specific details of the vulnerabilities that we identified because of the sensitive nature of the information. We have provided more detailed information and recommendations to New Mexico so that it can address the issues we identified. The findings listed in this summary report reflect a point in time regarding system security and may have changed since we reviewed these systems.

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We audited the City of Fresno’s Community Development Block Grant (CDBG) program. We selected the City based on prior findings identified by the U.S. Department of Housing and Urban Development (HUD) and continuing issues with the program. The objective of the audit was to determine whether the City administered its CDBG funds in accordance with HUD requirements, focusing on code enforcement, antigraffiti, and after school program activities; monitoring; and program income.The City did not administer its program in accordance with HUD requirements. Specifically it (1) did not meet HUD’s code enforcement requirements, (2) spent CDBG funds on general government expenses, (3) did not ensure that one program met a CDBG national objective, (4) did not properly monitor its subrecipient or City departments, (5) used its entitlement funds before its program income, and (6) did not report program income to HUD in a timely manner. This condition occurred because the City (1) lacked the capacity and experience to administer and implement the program, (2) did not have adequate procedures and controls in place, and (3) disregarded HUD requirements. As a result, it used CDBG funds for $163,555 in ineligible costs and more than $7.9 million in unsupported costs and put $428,373 at risk over the next year of similar questionable use.We recommend that the Acting Director of HUD’s San Francisco Office of Community Planning and Development require the City to (1) repay the program $163,555 from non-Federal funds, (2) support the eligibility of more than $7.9 million in CDBG costs or repay the program from non-Federal funds, (3) suspend funding to its code enforcement program until it can show that it has implemented controls, addressed its capacity issues, and understands and abides by HUD requirements, (4) implement policies and procedures to ensure that $428,373 in CDBG funds is used in accordance with program requirements, and (5) provide training

The Plan identifies the products OIG intends to issue during the specified time frame. The list of products reflects what we can reasonably accomplish with theavailable resources, and we recognize that work of more immediate concern may arise requiring us to adjust our priorities.

TrailBlazer Health Enterprises, LLC (TrailBlazer), understated the Medicare segment pension assets by $1.2 million as of April 30, 2013. In addition, TrailBlazer understated Medicare's share of the Medicare segment excess pension assets by $1.2 million as of April 30, 2013, as a result of the Medicare segment closing.

TrailBlazer Health Enterprises, LLC, did not claim $4.3 million of allowable Medicare pension costs on its Final Administrative Cost Proposals for fiscal years 2005 through 2011.

Head Start grantees are required to have Single Audits conducted in accordance with the Office of Management and Budget Circular A 133 (also known as A-133 audits) for fiscal years beginning before December 26, 2014. The Administration for Children and Families (ACF) had a process in place to ensure that (1) it responded in a timely manner to Head Start grantees' A 133 audit findings by issuing management decisions on those findings within the required 6 months and (2) Head Start grantees took corrective action on A-133 audit findings. Specifically, for Region IX Head Start grantees (located in Arizona, California, Hawaii, and Nevada) that submitted audit reports to the Federal Audit Clearinghouse, ACF resolved recurring audit findings in accordance with Federal requirements and ACF policies and procedures. Accordingly, this report contains no recommendations.

EAC OIG, through the independent public accounting firm of McBride, Lock & Associates, LLC, audited $9.0 million in funds received by the Puerto Rico State Elections Commission under the Help America Vote Act. The objectives of the audit were to determine whether the Commission: 1) used payments authorized by Sections 101, 102, and 251 of the Grant in accordance with Grant and applicable requirements; 2) accurately and properly accounted for property purchased with Grant payments and for program income; 3) Met HAVA requirements for Section 251 funds for creation of an election fund, providing required matching contributions, and meeting the requirements for maintenance of a base level of state outlays, commonly referred to as Maintenance of Expenditures (MOE).