Federal Reports

The lack of board members continues to be the biggest risk to CSB operations.

In accordance with the Reports Consolidation Act of 2000, the Federal Election Commission Office of Inspector General identifies the most serious management and performance challenges facing the Commission and provides a brief assessment of the Commission’s progress in addressing those challenges.

In accordance with the Reports Consolidation Act of 2000, this report provides a summary of the top management and performance challenges facing the Commission, noting management’s progress in addressing these challenges.

The VA Office of Inspector General (OIG) assessed whether the Veterans Health Administration (VHA) and the Office of Electronic Health Record Modernization (OEHRM) effectively implemented the patient scheduling component of VA’s new electronic health record system at two sites in 2020. They were the Chalmers P. Wylie VA Ambulatory Care Center in Columbus, Ohio, and the Mann-Grandstaff VA Medical Center in Spokane, Washington.The new scheduling system is part of VA’s $10 billion electronic health record contract with Cerner and has the potential to transform VHA scheduling. However, the OIG found that VHA and OEHRM knew of but did not fully resolve significant limitations before and after implementing the system at the Columbus and Spokane facilities, leading to reduced effectiveness and increased risk of patient care delays.With limited guidance and inadequate training on how to respond to unresolved issues, schedulers developed work-arounds. VHA employees also worked with Cerner to try to correct issues using a ticketing process that was ineffectively managed; OEHRM did not assess Cerner’s compliance with contract terms for handling tickets.VA planned to implement the system at all (11) Veterans Integrated Service Network 20 facilities by December 2021. However, OEHRM paused future deployment in March 2021 to conduct a strategic review of the full electronic health record program.VA needs to ensure VHA and OEHRM take appropriate steps to resolve issues with the new scheduling system as soon as possible. The OIG issued eight recommendations: (1) improving training for scheduling, (2) better engaging schedulers in testing and improvements, (3) issuing guidance on measuring patient wait times, (4) tracking help tickets consistent with contract terms; (5) developing a strategy to promptly resolve identified issues, (6) developing oversight of schedulers’ accuracy, (7) evaluating patient care timeliness, and (8) providing guidance to consistently address system limitations.

VA manages about $10 billion each year in medical supplies and equipment inventory. In March 2019, VA directed the deployment of the Defense Department’s Defense Medical Logistics Standard Support (DMLSS) System to modernize and standardize Veterans Health Administration (VHA) supply chain management and replace up to 12 legacy systems. The deployment is expected to cost $2.2 billion over 15 years.The Office of Inspector General (OIG) reviewed VA’s oversight and coordination of the system’s implementation at the pilot site, the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois, to identify challenges that could affect future deployments.The OIG found operational gaps that should be addressed to prevent recurrence and delays at future sites. The system did not meet more than 40 percent of the high priority essential business requirements identified by Lovell staff when it deployed on August 4, 2020. Consequently, Lovell staff had to develop work-arounds to maintain day to day operations.Although VA’s acquisition framework policies outline a process to ensure the DMLSS system meets high priority requirements, the VA Logistics Redesign (VALOR) program manager did not follow the framework as required. The VALOR program office tasked with overseeing the effort also had a slow and unsteady start. The office was created in early 2019 to manage deployment of the DMLSS system but did not receive funding until January 2020. Additionally, VALOR did not effectively coordinate with key stakeholders early enough to minimize operational issues. VALOR also had six program managers since VA made the decision to adopt the DMLSS system.VA concurred with OIG recommendations and reported progress on the VALOR program office aligning the DMLSS deployment process with VA’s acquisition framework policy; better identifying unmet high priority business requirements and post deployment challenges; and obtaining adequate staffing and stable leadership.

We performed an audit of the Tennessee Valley Authority’s (TVA) Internet perimeter. Our objective was to identify cybersecurity weaknesses in TVA’s Internet perimeter through penetration testing. In summary, we identified some vulnerabilities in TVA’s internet perimeter. Specifically, we (1) downloaded files related to TVA’s disposal of coal ash that were marked as confidential, (2) accessed a Web site related to river operations that used weak authentication, and (3) found TVA’s password complexity requirements on a TVA publicly available Web site. We recommended TVA ensure (1) documents related to TVA’s disposal of coal ash for public release are properly reviewed and TVA information classification markings removed, (2) Web sites follow TVA policy for authentication, and (3) removal of TVA’s password complexity rules from TVA’s publicly accessible Web sites. TVA management provided actions they plan to take or have taken to address each of our recommendations.

What We Looked AtWe queried and downloaded 75 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between July 1, 2021 and September 30, 2021, 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 16 grantees that require prompt action from DOT’s Operating Administrations (OA). The auditors also identified questioned costs totaling $9,236,974 for five grantees. Of this amount, $44,115 was related to COVID-19 formula grants for the Federal Aviation Administration’s CARES Act Airport Grant Agreement Program. 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 $9,236,974, if applicable.

The VA Office of Inspector General (OIG) conducted a national review of stat community care consults generated during the outset of the COVID-19 pandemic to evaluate consult processes. Patient involvement in care urgency disagreements and reporting of adverse events in community care were also reviewed. When the OIG identified deficiencies in processes, electronic health records (EHRs) of the patients at issue were further examined for potential negative outcomes. The OIG did not identify any negative care outcomes.For the 2,236 stat community care consults generated from March 20, 2020, through June 30, 2020, that were in an active, scheduled, or completed status, the OIG reviewed the community medical provider documentation contained in patients’ EHRs and determined the following:• Care was not provided within 24 hours for 379 (16.9 percent) consults.• Care was provided as requested for 2,049 consults (91.6 percent) irrespective of being within or outside of 24 hours.The OIG conducted an electronic survey regarding facility stat community care consult processes and identified:• Approximately 10 percent of facilities reported not processing stat consults in community care. Of these, almost three-fourths referenced difficulties meeting consult requirements, such as preauthorization of care, obtaining community provider medical documentation, and completing consults within 24 hours.• Of the facilities that responded, almost one-fourth indicated the chiefs of staff or designees changed the urgency statuses of consults from stat to routine without collaborating with the referring providers.The OIG made six recommendations to the Under Secretary for Health related to community care resources, facility practices, and VHA requirements that specifically focused on stat community care consults:• Retrieval of medical records and administrative closure• Urgency override process• Patient involvement in clinical decision-making regarding consult urgency status• Time frame for adjudicating clinical appeals• Adverse event–reporting processes