Federal Reports

What We Looked AtThe primary mission of the Federal Motor Carrier Safety Administration (FMCSA) is to reduce crashes, injuries, and fatalities involving large trucks and buses. To that end, FMCSA regulates commercial driver’s license (CDL) holders involved in interstate commerce and the transportation of hazardous materials. In the last 5 years, fatalities in crashes involving large trucks or buses increased by 12.4 percent, from 4,505 in 2014 to 5,064 in 2019. Federal regulations describe the minimum standards States must meet to comply with the Federal CDL program and permits FMCSA to review each State CDL program to determine compliance. Accordingly, the objective for this self-initiated audit was to assess FMCSA’s oversight of States’ actions to disqualify commercial drivers when warranted. What We FoundStates did not timely transmit electronic conviction notifications 17 percent of the time. Specifically, we estimate that States of Conviction did not timely transmit 18 percent of 2,182 major offenses and 17 percent of 23,628 serious traffic violations in our universe. We also estimate that 11 percent of 2,182 major offenses were not timely posted and 2 percent of 23,628 serious traffic violations in our universe were not posted to driver records at all. While States did take action to disqualify CDLs when appropriate, with exceptions, FMCSA’s evaluation of paper conviction notifications is limited by States’ processes for recording and tracking convictions sent by mail. Furthermore, FMCSA's Annual Program Review process lacks adequate quality control measures for verifying that State CDL programs meet Federal requirements. Finally, State noncompliance with Federal CDL disqualification requirements and other State actions pose challenges for FMCSA’s oversight. For example, some States offered administrative appeals to out-of-State drivers, overturned disqualifications, and backdated CDL disqualification periods. As a result, some drivers served shorter disqualification time periods than Federal law requires. Our RecommendationsWe made seven recommendations to strengthen FMCSA’s oversight of States’ actions to comply with Federal CDL disqualification requirements. FMCSA concurred with all seven recommendations, which we consider resolved but open pending completion of the planned actions.

The unclassified version of the SAR covers the period from October 1, 2020 through March 31, 2021, and reflects what the NSA OIG could release publicly about its work for that SAR Report Cover reporting period. The OIG issued 16 oversight products during the period, making 256 recommendations that we believe will be impactful in improving the economy, efficiency, and effectiveness of this critical Agency's operations. NSA's management agreed with all OIG recommendations that were made during the reporting period. The Director of the NSA and Congress previously received the classified version of the SAR in accordance with the IG Act.

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Sports adapted for athletes with disabilities can play a vital role in improving veterans’ quality of life. VA’s Office of National Veterans Sports Programs and Special Events (NVSPSE) granted $47 million to organizations with experience in managing adaptive sports programs from fiscal year (FY) 2017 to FY 2020.In December 2019, the VA Office of Inspector General (OIG) received a hotline complaint alleging fraud in how the NVSPSE was “closing out” adaptive sports grants—bringing a grant to an end after determining recipients have completed all requirements. The OIG examined whether officials effectively managed the program to ensure compliance with applicable laws and regulations. The team also examined whether grant recipients were reimbursed on time.The OIG did not find evidence of fraud in the grant closeout process; however, it found that the NVSPSE was not effectively managing the program. The NVSPSE’s director had not established adequate internal controls, including developing standard operating procedures for managing adaptive sports grants. As a result, the NVSPSE could not effectively evaluate risks from grant recipients, did not reimburse some recipients’ expenses on time, did not always close out grants on time, and did not appropriately authorize extensions for using funds.By not closing out grants on time, the NVSPSE failed to free up about $346,000 that could have been used for other purposes. It also improperly allowed recipients to spend $328,000 in FY 2017 appropriations outside the approved period and improperly reimbursed 19 recipients a total of about $247,000. These expenditures may have violated both the Purpose Statute and the Antideficiency Act.The OIG made seven recommendations to improve management of the adaptive sports grants program and to determine whether Purpose Statute or Antideficiency Act violations occurred.

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 Portland Health Care System and multiple 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.The healthcare system executive leadership team appeared stable, with all positions permanently assigned. Employee survey items revealed opportunities to improve satisfaction and staff feelings of moral distress at work. Patients appeared satisfied with their inpatient and specialty care experiences, but leaders have opportunities to improve the patient-centered medical home experience. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify substantial organizational risk factors. However, the OIG noted concerns with the healthcare system’s identification of sentinel events. Leaders were generally 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 17 recommendations for improvement in seven areas:(1) Quality, Safety, and Value• Improvement action implementation and monitoring• Root cause analyses(2) Medical Staff Privileging• Provider exit review forms(3) Medication Management• Aberrant behavior risk assessments• Urine drug testing• Informed consent• Patient follow-up(4) Mental Health• Patient follow-up• Suicide prevention training(5) Care Coordination• Life-sustaining treatment decision notes(6) Women’s Health• Women veterans health committee reporting and membership(7) High-Risk Processes• Standard operating procedures• Storage area humidity levels• Staff training