Federal Reports

Objective: To (1) evaluate internal controls over the accounting and reporting of administrative costs by the Puerto Rico Disability Determination Services (PR-DDS) for Fiscal Years (FY) 2017 and 2018; (2) determine whether the administrative costs claimed on the most recently submitted Form SSA-4513 were allowable and properly allocated; (3) reconcile funds drawn down with claimed costs; and (4) assess the general security controls environment.Note: 5 of 20 recommendations not published (sensitive).

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 North Florida/South Georgia Veterans Health System, which includes the Malcom Randall VA Medical Center in Gainesville and the Lake City VA Medical Center . The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the review, the assistant director position had been vacant since 2019, with the Deputy Director and the Associate Director, Lake City sharing the responsibilities. All but one of the assigned leaders had worked together for over one year. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Selected patient experience scores implied general satisfaction. However, survey results also highlighted opportunities to improve satisfaction for male and female veterans in inpatient and outpatient settings.The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued six recommendations for improvement in four areas:(1) Quality, Safety, and Value• Surgical work group attendance(2) Registered Nurse Credentialing• Primary source verification(3) Care Coordination• Receiving physician identification• Medication list transmission(4) High-Risk Processes• Staff training

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 Boston Healthcare System and multiple outpatient clinics in Massachusetts. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The system’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together for over six years. Selected employee satisfaction survey responses demonstrated satisfaction with leaders and maintenance of an environment where staff felt respected and discrimination was not tolerated. Patient experience survey data indicated satisfaction with the care provided.Executive leaders were able to speak in depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance. The inspection team reviewed accreditation agency findings and did not identify any substantial organizational risk factors. However, the OIG identified deficiencies with institutional disclosures of adverse events.The OIG issued eight recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Institutional disclosures(2) Quality, Safety, and Value• Peer review process(3) Mental Health• Suicide risk screening(4) Care Coordination• Patient transfer policy• Monitoring and evaluation of patient transfers• Transfer forms• Medication list transmission• Nurse-to-nurse communication

The Office of Inspector General (OIG) completed a final action verification of all three recommendations in our September 2018 interim report, Single Family Housing Guaranteed Loan Program—Liquidation Value Appraisals—Interim Report (Audit Report 04601-0001-23(1)).

Patching is the process for updating products and systems. Patches correct security and functionality problems in software and firmware. We performed an audit of the Tennessee Valley Authority’s (TVA) patching of Windows® desktops and laptops to determine if high-risk vulnerabilities on desktops and laptops were patched in accordance with TVA policy and best practices. We found (1) TVA policies and procedures aligned with best practices, (2) the majority of Windows® desktops and laptops managed by TVA’s automated patching system were patched for high-risk vulnerabilities in accordance with TVA policy, and (3) TVA had mitigated vulnerabilities for Windows® desktops and laptops that had not received updates. However, although the majority of Windows® workstations were managed by TVA’s automated patching system, we found some desktops and laptops were at potential risk of compromise.