Federal Reports

The Transportation Security Card Program Assessment (Public Law 114-278) requires DHS to assess the effectiveness of the Transportation Security Card Program and to prepare a corrective action plan (CAP) to respond to any findings. Our objective was to determine DHS’ compliance with the public law. We determined that DHS did not fully comply with the public law. TSA and the Coast Guard prepared, and DHS submitted, a CAP to Congress in June 2020. Although the CAP identified corrective actions for one area, it did not address four issues we consider significant. We recommended that DHS, in consultation with TSA and Coast Guard, re-evaluate the assessment to determine if further corrective actions are needed or justify excluding significant issues from the CAP. DHS did not concur with the recommendation, but we consider DHS’ actions partially responsive to the recommendation. We consider the recommendation open and unresolved.

We did not substantiate the allegations that a tribal administrator misused tribal funds.

OIG evaluated OASCR’s oversight of the civil rights complaints process.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 19: VA Rocky Mountain Network in Glendale, Colorado, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The VISN’s executive leadership team had worked together for nearly six months at the time of the OIG’s review. All members of the leadership team were permanently assigned, and two members had over 30 years of VA experience. Selected survey scores related to employees’ satisfaction with the VISN executive team leaders were generally higher than VHA averages. However, the Deputy Network Director had opportunities to improve employee perceptions of leadership. Patient experience survey scores were similar to VHA averages.The OIG’s review of access metrics and clinical vacancies did not identify any substantial organizational risk factors. The executive leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. They were also knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning metrics and should continue to take actions to sustain and improve performance.The OIG issued four recommendations for improvement in three areas:(1) Quality, Safety, and Value• Peer review summary data(2) Medical Staff Credentialing• Physician credential file review(3) Women’s Health• Quarterly program updates• Staff education gaps assessments

In follow-up to the VA Office of Inspector General (OIG) report, Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas, the OIG conducted a healthcare inspection to evaluate progress in responding to pathology reading errors identified during a look-back review of cases interpreted by Dr. Robert Levy between September 2005 and October 2017. The OIG determined facility processes related to disclosure of the pathology errors and amending patients electronic health records generally met Veterans Health Administration policy requirements, but opportunities for improvement existed.Look-back reviewers categorized cases according to their disagreement with the original diagnosis and potential harm to the patient (level 0–3). Cases categorized as level 2 or level 3 diagnostic errors were referred to a Clinical Review Team to determine the impact on patient care and need for clinical and institutional disclosure. The OIG determined the facility made reasonable efforts to conduct disclosures, completing all but six of the institutional disclosures and 76.5 percent of the clinical disclosures recommended by the Clinical Review Team. The OIG noted an absence of a clearly defined process for clinical providers to alert the Clinical Review Team if later changes in a patient’s health required reconsideration of institutional disclosure.The look-back review coordinator entered amended pathology reports into the electronic health record for patients identified with level 3 diagnostic errors. However, the facility struggled with completing amended reports for patients with level 2 diagnostic errors—fewer than 5 percent of the level 2 amended reports were completed as of March 2021.The OIG made two recommendations to the Under Secretary for Health related to documentation of clinical disclosures and provider communication to the Clinical Review Team. One recommendation was made to the Facility Director related to amendment of the remaining pathology reports.

The Postal Service’s customer care phone number, 1-800-ASK-USPS, is one of the primary channels for customers to connect with the Postal Service. When customers call 1-800-ASK-USPS, their call is initially handled by an Interactive Voice Response (IVR) system. Using voice commands or keypad inputs, customers can navigate the IVR system to get information or complete tasks, such as finding the location and hours of post offices or tracking a package. Survey results suggest that customer experiences with the Postal Service’s IVR system are improving. Between FY 2019 and FY 2020, customers reported improved satisfaction with the IVR experience and more customers reported their inquiry was resolved. However, opportunities exist for continued improvement. In FY 2020, roughly one-quarter of IVR survey respondents were very dissatisfied with their IVR experience.