Federal Reports

The OIG determined whether VA complied with the requirements of the Payment Integrity Information Act of 2019 (PIIA) for fiscal year 2020. Several requirements focus on improper payments, or any payment that should not have been made or was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.The review team found that VA did not comply with PIIA because it did not satisfy two of six requirements:• to meet reduction targets for two programs assessed to be at risk for improper payments, and• report an improper payment rate of less than 10 percent for five VA programs and activities that had improper payment estimates in the materials accompanying the annual financial statement.VA satisfied the other four requirements:• to post the annual financial statement for the most recent fiscal year and accompanying materials on PaymentAccuracy,• publish improper payment estimates for programs susceptible to significant improper payments in these materials,• publish corrective action plans for each program for which an estimate above the statutory threshold was published in these materials, and• conduct improper payment risk assessments for each program with annual outlays greater than $10 million at least once in the last three years.In fiscal year 2020, VA reported improper payment estimates totaling $11.37 billion for 12 programs and activities. To VA’s credit, it noted a decrease in improper payment estimates two years in a row and a decrease in its improper payment rates for nine programs and activities.The OIG recommended the under secretary for benefits ensure the Pension Program meets its reduction target. The OIG also recommended the acting deputy under secretary for health ensure the Purchased Long-Term Services and Supports Program meets its reduction target and reduce improper payments for five VA programs to below 10 percent.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Roseburg VA Health Care System, which includes the Roseburg VA Medical Center and three outpatient clinics in Oregon. 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; Medical Staff Privileging; 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.When the team conducted this inspection, the healthcare system’s leaders had worked together for 16 months, with the most tenured leader permanently assigned in 2016. Survey results revealed opportunities to improve staff feelings of “moral distress” in the workplace. Patients appeared generally satisfied, but there were opportunities to improve the experiences of women veterans.The OIG identified concerns with root cause analysis action implementation and outcomes measurement. Leaders were knowledgeable about employee satisfaction and patient experiences. However, they had opportunities to improve their knowledge of VHA data and/or system-level factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures.The OIG issued 13 recommendations for improvement in six areas:(1) Quality, Safety, and Value• Root cause analyses(2) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit reviews(3) Mental Health• Staff training(4) Care Coordination• Goals of care conversations(5) Women’s Health• Designated women’s health providers• Women veterans health committee(6) High-Risk Processes• Standard operating procedures• Staff training• Monthly staff continuing education

The Office of the Inspector General determined some requirements of the Tennessee Valley Authority’s procedures related to arc flash protection and engineering calculations were not performed. Specifically, (1) some arc flash hazard analyses were not performed, (2) arc flash hazard analyses were not periodically reviewed, (3) some arc flash hazard analyses were incomplete or inaccurate, and (4) some hazards were not accurately communicated on warning labels as required. In addition, we found arc flash hazard calculations were not formatted, approved, or maintained as required. We also determined personal protective equipment was maintained and most training was completed as required by the arc flash procedure; however, we identified a few individuals who had not completed the assigned curriculum. Lastly, we identified an opportunity for improvement related to developing a Transmission and Power Supply specific arc flash procedure. Based on issues identified during the course of our evaluation, Transmission and Power Supply performed an assessment of its arc flash program and developed an action plan to address identified gaps.

The Peace Corps Office of Inspector General (OIG) reviewed the Peace Corps’ medicalevacuation and care of Volunteer Ezeani to determine if the agency was sufficiently prepared torespond to this medical emergency and assess whether the medical evacuation of VolunteerEzeani was appropriately managed.

While some of HUD’s efforts to improve its hiring and human capital functions and reduce its average time-to-hire have been successful, HUD’s hiring process overall was not efficient. HUD’s Office of the Chief Human Capital Officer (OCHCO), which is responsible for developing and implementing policies and procedures associated with human capital management, set a goal to reduce the average time-to-hire but did not meet this goal. OCHCO must implement efforts to improve HUD’s hiring and human capital functions and increase hiring efficiency, as defined in its own human capital operating plans.Hiring process owners, including program office hiring managers and administrative staff, received limited and inconsistent training on the hiring process and were not aware of the roles or responsibilities in the hiring process. The unclear roles and responsibilities, along with the inconsistent training, impacted HUD’s ability to hire efficiently.Additionally, OCHCO had inconsistent and unreliable hiring data due to the manual nature of the data input and the lack of interaction among the various data-tracking tools. As a result, OCHCO may not fully understand how well HUD’s hiring process is operating or where its shortcomings exist. The unreliable hiring data impede OCHCO’s and the program offices’ ability to properly identify when to take actions for improvement.We offer 11 recommendations to improve HUD’s hiring process. Six of the recommendations are aimed at process reform, and five recommendations are designed to support data improvement. The status of each recommendation is “unresolved-open.”

What We Looked AtAs the Federal Aviation Administration’s (FAA) operational arm, Air Traffic Organization (ATO) is responsible for providing safe and efficient air navigation services in U.S. controlled airspace. ATO provides air navigation services in over 17 percent of the world’s airspace and includes large portions of international airspace over the Atlantic and Pacific Oceans and the Gulf of Mexico. Until recently, FAA ATO had never applied the high-impact security categorization rating to any of its information systems. While many of these systems provide safety-critical services and would have adverse high impact to FAA’s mission in the event of system failure, and on the safety and efficiency of the National Airspace System (NAS), FAA categorized all of them as low or moderate. Given the importance of ATO’s information systems to air traffic control security and traveler safety, we initiated this audit. Our audit objectives were to assess (1) FAA’s information system categorization process and (2) the security controls that FAA has selected for the systems it recently re-categorized as high impact. Our RecommendationsFAA concurred with all six of our recommendations to enhance FAA’s categorization process, and mitigate security risks until the Agency selects and implements high security controls for its re-categorized high-impact systems. THE DEPARTMENT HAS DETERMINED THAT THIS REPORT CONTAINS SENSITIVE SECUITY INFORMATION (SSI) that is controlled under 49 CFR parts 15 and 1520 to protect Sensitive Security Information exempt from public disclosure. For U.S. Government agencies, public disclosure is governed by 5 U.S.C. § 552 and 49 CFR parts 15 and 1520. SSI will be redacted from the report version posted on our website.

The objective of the performance audit was to determine whether the Procurement List (PL) addition process was transparent and performed efficiently, effectively, and in compliance with applicable laws, regulations, and policies.To answer the audit objective, the auditors interviewed key officials and reviewed all PL additions and PL transaction data during fiscal years (FY) 2018, 2019, and 2020. The team also assessed 1) the effectiveness of the policies, procedures, and practices employed when approving the addition or removal of products and services to or from the PL, 2) Central Nonprofit Agency (CNA) processes for producing and providing PL addition packages, and 3) how the Procurement List Information Management System (PLIMS) supports the processing of additions to and deletions from the PL.Overall, the performance audit concluded that, in general, the PL additions process complied with applicable laws and regulations, and that the Commission has improved its guidance to the CNAs regarding the submission of transaction packages to PLIMS, which led to improvements in the approval rates of PL addition packages and reduced overall PL addition cycle time. There were also improvement opportunities in four areas of the Commission’s process for completing PL additions.The report offers 13 recommendations to help the Commission improve its controls over the PL additions process as well as improve the efficiency and effectiveness of the process in helping the Commission achieve its policy goals.