Federal Reports

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 Salt Lake City Health Care System. 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; Medication Management: Remdesivir Use in VHA; 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.At the time of the OIG’s inspection, the Chief of Staff and Director had served in their roles since 2012 and 2017, respectively. However, the remaining three executive leaders had assumed their roles within the past 10 months. Employee survey results demonstrated satisfaction with most executive leaders and maintenance of a work environment where staff felt respected and discrimination was not tolerated. Patient survey results indicated general care satisfaction among male veterans, but opportunities to improve female veterans’ experiences. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive 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 six recommendations for improvement in three areas:(1) Mental Health• Suicide prevention training(2) Care Coordination• Monitoring and evaluation of inter-facility transfers• Transfer form completion• Documentation of active medication lists• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior training

Our objective was to determine if the Postal Service has an effective security posture to protect its Information Technology (IT) infrastructure from external cyberattacks and prevent unauthorized access to restricted data.

What We Looked AtWe queried and downloaded 70 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between April 1, 2021 and June 30, 2021. We used the reports to identify significant findings related to programs directly funded by the Department of Transportation (DOT).What We FoundThe reports contained a range of findings that impacted DOT programs. The auditors reported significant noncompliance with Federal guidelines related to 13 grantees that require prompt action from DOT's Operating Administrations (OA). The auditors also identified questioned costs totaling $32,153,264 for eight grantees. Of this amount, $31.2 million was related to Amtrak and $212,788 to COVID-19 Formula Grants for the Rural Areas Program.RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $32,153,264, if applicable.

Kevin Nelson, a resident of New York, pleaded guilty in U.S. District Court, Eastern District of New York, on August 30, 2021, to Aggravated Identity Theft for his involvement in an Amtrak eVoucher scheme. Nelson and his co-conspirators used stolen credit card and personal information to make unauthorized purchases of Amtrak tickets and then cancelled or exchanged those tickets for eVouchers. Subsequently, they sold the fraudulently obtained eVouchers on the internet. The approximate loss to Amtrak from the scheme is $450,000. Nelson’s sentencing is pending.

Account Identifier Code (AIC) 553, Refund Postage and Fees, is used to record refunds of customers postage and fees paid for special services not received. OIG data analytics identified the Norristown Tri‑County Post Office had about $266,790 recorded to AIC 553 from January 1, 2020, to December 31, 2020, the highest in the nation. For fiscal year (FY) 2020, the total was $248,298 — 48 percent of the total for the DE-PA2 district. For FYs 2018 and 2019, the totals for AIC 553 were only $691 and $967 (0.53 percent and 0.58 percent of the district total), respectively.The objective of this audit was to determine whether postage and fee refunds are valid and properly supported and processed at the Norristown Tri‑County Post Office.

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