Federal Reports

Our objective for this report was to identify the internal control weaknesses that allowed a potential identity theft crime to occur in Chicago and to assess the company’s processes for overseeing and safeguarding items at selected stations.We found that the company has taken steps to strengthen its Lost and Found program to include addressing issues that contributed to an employee theft of 13 state and government customer identification cards and 21 social security cards from the Chicago Union Station Lost and Found program in October 2020. Additionally, we found the company is securing sensitive and high-value items at the stations we reviewed, and, in 2018, automated inventory controls through its use of the third-party software system, Chargerback. We identified opportunities that could further improve the company’s Lost and Found program to include 1) improving program monitoring by station managers, 2) ensuring staff are well trained, 3) resuming monthly lost and found reporting to station management, and 4) provide guidance on how employees should safeguard items found at maintenance yards and on trains and how quickly the items should be transferred to the Lost and Found area. The company agreed with these observations and plans to take corrective actions.

As part of our annual audit plan, we audited the Tennessee Valley Authority's (TVA) utility-scale Solar Purchased Power Agreements (PPA). Our audit objectives were to determine if TVA has (1) approached Solar PPAs to better understand the industry and market trends being developed prior to entering into multiple agreements and (2) developed Solar PPAs to recognize positive financial value earlier in the term of the PPAs. The scope of our review was utility-scale solar PPAs in place as of December 31, 2020. We found TVA had (1) taken a measured approach to solar PPAs to better understand the industry and market trends and (2) generally developed solar PPAs to recognize positive financial value or breakeven.(Summary Only)

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ quality, safety, and value (QSV) programs. This evaluation examined committee processes for QSV oversight functions, protected peer reviews of clinical care, utilization management, and patient safety.This report describes QSV-related findings from healthcare inspections performed at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG reviewers evaluated meeting minutes, protected peer reviews, root cause analyses, annual patient safety reports, and other relevant documents. The results in this report are a snapshot of Veterans Health Administration performance at the time of the fiscal year 2020 OIG reviews.The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses in various key QSV functions, noted repeat findings from the fiscal year 2018 and 2019 QSV evaluations, and issued four recommendations related to the• implementation of action items recommended by committees responsible for QSV oversight,• peer review of all applicable suicide deaths,• inclusion of required processes in root cause analyses, and• implementation and monitoring of action items resulting from root cause analyses.

We are pleased to provide the Office of Inspector General (OIG) Quarterly Audit Recommendation Status Report. As of July 30th, 2021, there are 81 open recommendations, 36 of which are considered “Overdue,” and another 26 reported by management as “Implemented.” Since the date of the OIG’s last semiannual report to Congress, dated March 31st, 2021, 13 new recommendations were added, and no recommendations were closed.

The VA Office of Inspector General (OIG) reviewed allegations referred by Congressman Ron Kind regarding the care of a patient at the Tomah VA Medical Center (facility) who subsequently died from a presumed anoxic brain injury.The OIG did not substantiate staff over-sedated the patient. The OIG found that physicians’ failure to provide adequate benzodiazepine dosing to address the patient’s delirium tremens, review the patient’s abnormal electrocardiogram prior to haloperidol administration, and transfer the patient earlier likely contributed to the patient’s deterioration and ultimate death.The OIG substantiated that a non-VA paramedic documented that the oxygen flow was not active. Facility leaders and staff reported lack of knowledge about the failed oxygen delivery. The OIG did not substantiate that staff failed to document non VA emergency medical services.Nursing staff did not complete all required alcohol withdrawal assessments. A physician improperly ordered restraints, nurses failed to obtain full vital signs while the patient was in restraints, and nurses did not receive restraint training as expected.The OIG substantiated that facility leaders and staff did not communicate initiation of emergency detention with the patient’s family; however, notification is not required. Leaders did not conduct an institutional disclosure with the patient’s family timely or in person and did not provide a relevant update.The OIG made 10 recommendations to the Facility Director related to education regarding alcohol withdrawal, cardiac risks, review to determine causes of failed oxygen delivery, root causes and performance deficiencies, workgroup outcome, alcohol withdrawal assessment protocol adherence, restraint management and training, compliance with admission criteria, emergency detention, and institutional disclosure.

Our objective was to evaluate the effectiveness of U.S. Postal Inspection Service policies and procedures for managing cryptocurrency in its law enforcement activities. Cryptocurrency is a decentralized form of digital currency that uses a blockchain, or public ledger, to record transactions. The anonymity of cryptocurrency transactions and the significant fluctuations in the value of cryptocurrency create opportunities for abuse or theft when used during law enforcement activities. We evaluated the Postal Inspection Service’s use and seizure of cryptocurrency in cases closed in fiscal years (FY) 2019 and 2020. The Postal Inspection Service established the Cryptocurrency Fund Program (the Program) in 2017 to establish standards and policies to account for cryptocurrency transactions and reduce operational risk.