Federal Reports

We found that SBA established its May 2020 COVID-19 Reconstitution Plan in accordance with applicable federal guidance. We identified issues with the implementation of the reconstitution plan that should be addressed to help the agency safeguard its employees from contracting and spreading COVID-19 in the workplace.We found the agency did not follow occupancy procedures for advancing or reverting phases at its Washington, DC headquarters. SBA also did not implement exposure tracking protocols to ensure it consistently traced COVID-19 cases. We found the agency did not consistently notify its staff of presumed or confirmed COVID-19 cases in the sampling we analyzed. SBA did not consistently contact potentially exposed personnel and ensure employees completed 14-day quarantine periods.SBA replaced the reconstitution plan with its new COVID-19 Workplace Safety Plan in February 2021. We made one recommendation for SBA to enforce the requirements of its new workplace safety plan by consistently applying procedures for occupancy and exposure tracking and to accurately record and maintain supporting documentation for all reported COVID-19 cases. SBA management agreed with our recommendation and planned actions resolve the recommendation.

An Electronic Technician based in Boston resigned from the company on July 12, 2021, prior to his disciplinary hearing. From March 30, 2021, through April 30, 2021, the former employee violated company policies by fraudulently claiming and accepting payment for over 62 hours of straight time and overtime hours that he did not work or was not authorized to work, for which he received over $2,825 in compensation. When we interviewed the employee, he initially lied about his actions but eventually admitted that he did not work all of the hours he claimed. The technician is not eligible for rehire.

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 Boise VA Medical Center and five outpatient clinics in Idaho and 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.At the time of the OIG’s virtual review, the executive leaders had worked together for over three months. Employee survey results for selected leadership questions were similar to or better than the VHA average. Patient experience survey results were higher than VHA averages, and patients appeared satisfied with their care. The OIG’s review of accreditation findings, sentinel events, and large-scale disclosures did not identify any substantial organizational risk factors. During the institutional disclosures review, the OIG identified surgical complications in two patients that appeared to meet peer review criteria but were not reviewed. The executive leaders were generally knowledgeable, within their tenure and scope of responsibilities, about VHA data and/or medical center-level factors contributing to Strategic Analytics for Improvement and Learning measures.The OIG issued 10 recommendations for improvement in six areas:(1) Medical Staff Privileging• Provider exit review forms(2) Medication Management• Pain management committee processes(3) Mental Health• Suicide prevention outreach activities• Suicide prevention training(4) Care Coordination• Life-sustaining treatment decision progress notes(5) Women’s Health• Gynecologic care coverage• Designated women’s health primary care providers• Women veterans health committee meeting attendance• Women veterans program manager duties(6) High-Risk Processes• Standard operating procedures

What We Looked AtThrough its Logistics Center, the Federal Aviation Administration (FAA) maintains, repairs, and overhauls equipment for the National Airspace System (NAS). The Logistics Center is FAA’s only centralized distribution center for NAS inventory, valued at $735 million. Each year, it ships and receives approximately 200,000 parts to FAA field offices and other domestic and international customers. Previous reviews have found that FAA did not have sufficient controls in place to track and manage its inventory. Accordingly, we initiated this audit with the following objective: to determine if FAA has effective oversight controls for managing the NAS inventory, including controls to appropriately account for excess, obsolete, or unserviceable (EOU) items. What We FoundFAA lacks sufficient oversight controls for managing its NAS inventory and continues to maintain excessive quantities of old and unserviceable parts. In part, this is because FAA lost the automatic functionality for monitoring excess inventory levels after it transitioned to a new inventory management system. The transition to the new system also impacted FAA’s ability to track EOU inventory to final disposition and monitor exchange and repair (E&R) parts shipped to and from the field. Furthermore, FAA must manually recalculate inventory values for most E&R parts and faces about $1 million in quantity discrepancies. The lack of sufficient controls limits FAA’s ability to accurately report its inventory values and determine the stock levels it needs to support NAS systems. Our RecommendationsWe made seven recommendations to improve FAA’s ability to manage and provide oversight for the NAS inventory. FAA concurred with recommendations 1–4, 6, and 7. Thus, we consider these recommendations resolved but open pending an OIG review and FAA’s completion of planned actions. FAA partially concurred with recommendation 5 and provided an alternative action but did not describe the course of action it will take if parts are never returned or the impact of unreturned parts on its financial statements. Therefore, we consider recommendation 5 open and unresolved. We request that the Agency reconsider its position on this recommendation and provide us with its revised response within 30 days of the date of this report in accordance with DOT Order 8000.1C.

This report of investigation pertains to the actions of former EPA Chief of Staff Ryan Jackson and former Senior Advisor to the Region 9 Administrator Charles Munoz.