Federal Reports

ICE has taken various actions to prevent the pandemic’s spread among detainees and staff at their detention facilities. At the nine facilities we remotely inspected, these measures included maintaining adequate supplies of PPE such as face masks, enhanced cleaning, and proper screening for new detainees and staff. However, we found other areas in which detention facilities struggled to properly manage the health and safety of detainees. For example, we observed instances where staff and detainees did not consistently wear face masks or socially distance. In addition, we noted that some facilities did not consistently manage medical sick calls and did not regularly communicate with detainees regarding their COVID-19 test results. Although we found that ICE was able to decrease the detainee population to help mitigate the spread of COVID-19, information on detainee transfers was limited. We also found that testing of both detainees and staff was insufficient, and that ICE headquarters did not generally provide effective oversight of their detention facilities during the pandemic. Overall, ICE must resolve these issues to ensure it can meet the challenges of not only the COVID-19 pandemic, but future pandemics as well. We made six recommendations to improve ICE’s management of COVID-19 in its detention facilities. ICE concurred with all six recommendations.

Our objective was to determine if the Postal Service has adequate controls over awarding noncompetitive contracts and whether business scenario justifications were adequately supported.The goal of the Postal Service’s supply chain activities is to obtain the best value, which is generally achieved through competition. Competition brings market forces to bear and helps purchase/supply chain management teams compare the relative value of proposals and prices. Competition also encourages the adoption of innovative ideas and solutions and promotes fairness and openness that leads to public trust. However, there are business situations when the noncompetitive purchase method better suits or is needed to meet the business objectives of the Postal Service.

As a part of our IT Audit program, the OIG reviewed a Postal Service IT system to assess the security posture. This audit involved a technical review to identify potential issues and provide recommendations. The technical details of our work are shared directly with Postal Service management. Due to the sensitive nature of this information, we did not post details of our 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 Edith Nourse Rogers Memorial Veterans’ Hospital and three outpatient clinics in Massachusetts. 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; 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 executive leadership team had worked together for approximately eight months at the time of the OIG virtual review. Survey data revealed opportunities for the Chief of Staff to improve employee perceptions of leaders and the workplace, and the Associate Director Nursing and Patient Care Services to improve employee feelings of respect. The OIG’s review of the hospital’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued seven recommendations for improvement in three areas:(1) Mental Health• Suicide prevention training(2) Care Coordination• Transfer form completion• Medical record transmission• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee meeting attendance• Disruptive behavior and threat assessment training

The OIG’s administrative investigation examined the circumstances surrounding the death of a veteran on the Edith Nourse Rogers Memorial Veterans Hospital campus in Bedford, Massachusetts (the medical center). Mr. Timothy White was a resident of the Bedford Veterans Quarters (BVQ), an independent living facility operated by Caritas Communities, Inc. (Caritas), in space leased to it through VA’s enhanced-use lease program. A month after Mr. White was reported missing, his body was found in the emergency exit stairwell of the building that houses the BVQ. This stairwell down the hall from his room was VA property and not leased to Caritas.The VA police department’s failure to locate Mr. White resulted in part from the police and others at VA not considering the veteran an at-risk missing patient, which would have required a stairwell search. The Veterans Health Administration and the Office of Security and Law Enforcement lacked clear guidance regarding the obligations of VA police to search for nonpatients reported missing on VA property.VA police also did not discover Mr. White in the stairwell because of an improper order by the then police chief to cease patrols of the building in which Mr. White was found. The OIG found that the VA police chief exceeded his authority as both VA policy and the lease required VA police to patrol VA property.Lastly, because medical center staff mistakenly believed the emergency exit stairwells were not VA space, they did not clean them. The confusion among medical center leaders and staff regarding the lease scope and VA’s obligations stemmed from a lack of clear guidance from the Office of Asset and Enterprise Management. Routine police patrols and stairwell cleanings likely would have led to Mr. White being found earlier.VA concurred with the OIG’s seven recommendations to improve policies and procedures.

The Cybersecurity and Infrastructure Security Agency (CISA) cannot demonstrate how its oversight has improved Dams Sector security and resilience. We attribute this to CISA’s inadequate management of Dams Sector activities. Specifically, CISA has not:coordinated or tracked its Dams Sector activities;updated overarching national critical infrastructure or Dams Sector plans; orcollected and evaluated performance information on Dams Sector activities.In addition, CISA does not consistently provide information to the Federal Emergency Management Agency (FEMA) to help ensure FEMA’s assistance addresses the most pressing needs of the Dams Sector. CISA and FEMA also do not coordinate their flood mapping information. Finally, CISA does not effectively use the Homeland Security Information Network Critical Infrastructure Dams Portal to provide external Dams Sector stakeholders with critical information.As a result, CISA could improve its oversight, coordination, and communication to better support the Dams Sector security and resilience. These changes would enhance the Sector’s ability to adapt to the risk environment and decrease the likelihood of future dam failures and flooding events.