Federal Reports

The VA Office of Inspector General (OIG) conducted a review of select activities and challenges of Military Sexual Trauma (MST) Coordinators and Veterans Integrated Service Network Points of Contact in response to a request from Congressman Chris Pappas, Chairman of the House Veterans’ Affairs’ Subcommittee on Oversight and Investigations, and Congresswoman Julia Brownley, Chairwoman of the Women Veterans Task Force. The OIG also reviewed the culture of safety for patients requesting MST-related care.Sexual trauma experienced while serving in the military affects both women and men with potentially serious and long-term consequences. Psychological trauma, such as MST, also increases risk of physical health conditions such as cardiovascular disease, stroke, and diabetes. The Veterans Health Administration requires that each facility has a designated MST Coordinator with at least 20 percent of their time dedicated to protected administrative time.The OIG conducted a national survey and interviews to evaluate MST Coordinators duties and perceived challenges. Approximately 80 percent of the respondents reported having been assigned at least 20 percent or more of protected time. Thirty-nine percent reported inadequate resources to fulfill MST Coordinator administrative responsibilities. Based on analysis of survey results and interview information, the OIG found that insufficient protected administrative time, role demands, insufficient support staff, and inadequate funding and outreach materials challenged MST Coordinators’ ability to fulfill role responsibilities.Additionally, the OIG found that MST Coordinators who reported more dedicated time than other MST Coordinators did not necessarily serve at facilities with higher numbers of patients in MST related care.The OIG made one recommendation to the Under Secretary for Health to evaluate the sufficiency of current guidance and operational status regarding protected administrative time, administrative staff support, and funding for outreach, education, and special project resources, with consideration of MST Coordinators’ responsibilities, and take action as warranted.

The Transportation Security Administration (TSA) partially complied with the Act by establishing operational processes for routine activities within its Explosives Detection Canine Team (EDCT) program for surface transportation. Specifically, TSA has a national training program for canines and handlers, uses canine assets to meet urgent security needs, and monitors and tracks canine assets. However, TSA did not comply with the Act’s requirements to evaluate the entire EDCT program for alignment with its risk-based security strategy or develop a unified deployment strategy for its EDCTs for surface transportation. We recommended that TSA coordinate with its law enforcement agency partners to conduct an evaluation of the EDCT program and develop an agency-wide deployment strategy for surface transportation consistent with TSA's Surface Transportation Risk-Based Security Strategy. TSA concurred with both recommendations.

The Office of the Inspector General conducted a review of the Generation Services, Field Services organization to identify factors that could impact Field Services' organizational effectiveness. During the course of our evaluation, we identified many positive behaviors for engagement; however, we also identified needed improvements in behaviors in relation to first-line supervisors in three departments. We also identified risks to business operations, including experience, resource needs, such as funding, and staffing, and concerns related to reorganization efforts involving engineering. In addition, business partners discussed concerns, including areas for improvement related to support and collaboration.

The Veteran-Directed Care (VDC) program provides veterans with a budget to hire caregivers and purchase the goods and services that will best meet their needs and allow them to remain in their homes longer. The Veterans Health Administration (VHA) administers the program to maximize veterans’ functional independence and prevent or lessen the burden of disability on older, frail, and chronically ill patients, as well as their families and caregivers.Since fiscal year (FY) 2017, the VDC program has grown significantly. The number of veterans in the program has more than doubled to 4,400 in FY 2020. During this time, VDC program expenditures have increased by about 97 percent. The VA Office of Inspector General (OIG) audited the program to determine if VHA budgets and manages resources to ensure veterans in the program receive authorized goods and services to help them remain in their homes.The OIG found that VHA provided VDC services to veterans that addressed their care needs. However, due to weaknesses in program management, VHA lacks assurance that veterans are safe, provider agencies are paid correctly, and taxpayer dollars are properly spent. The OIG also identified opportunities for VHA to improve VDC policies and funding to ensure medical facilities can effectively implement and manage the program to help veterans stay in their homes.The OIG recommended the under secretary for health ensure program coordinators document their quarterly monitoring of the services veterans receive, improve the provider agency billing and payment process, and establish guidance to ensure veterans do not receive the same personal care services through the VDC program and the Family Caregiver Program. The OIG also recommended establishing procedures to assist in identifying staffing needs and tracking demand for program services.

The PRAC’s objective was to review pandemic-related federal contracts and identify first-time contractors and contracts awarded without competitive bidding. We found that first-time federal contractors received $4.4 billion worth of pandemic contracts in Fiscal Year 2020 and that $128 million was deobligated from contracts with first-time federal contractors during the same period. Additionally, we identified the four most common flexibilities identified to justify limited competition were urgency, only one source, simplified acquisition procedures, and authorized by statute. Of these, we found that 11% of non-competitive contracts used the “only one responsible source” authority, which is defined to be used when supplies and services are available from only one source in certain conditions. A limited sample revealed that 10 of 14 contracts either shouldn’t have selected that authority or had data entry errors within the Federal Procurement Data System.

This compendium analyzes currently open and unresolved recommendations. From March 2017 through March 2021, the EPA OIG issued nine semiannual reports to Congress that identified an average of 99 open recommendations and 18 unresolved recommendations issued by the OIG to the EPA. The total potential monetary benefit was, on average, $167 million for the open recommendations and $7.5 million for the unresolved recommendations.

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 Mann-Grandstaff VA Medical Center and multiple clinics in Idaho, Montana, and Washington. 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 site visit, the leadership team had worked together for about one month and had vacancies in two of four positions. Employee satisfaction survey results for the medical center and leaders were similar to or higher than Veterans Health Administration averages. Patients generally appeared satisfied with the care provided, but indicated opportunities to improve appointment scheduling for female veterans. The OIG’s review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors, but the OIG noted potential risks with the medical center’s expected electronic health record system implementation. Leaders were 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 13 recommendations for improvement in five areas:(1) Quality, Safety, and Value• Protected peer reviews• Root cause analyses(2) Medical Staff Privileging• Focused professional practice evaluations(3) Mental Health• Patient follow-up• Suicide prevention safety plans• Community outreach activities• Suicide risk training(4) Women’s Health• Gynecologic care coverage• Women veterans health committee• Quality assurance data collection and tracking• Women veterans program manager duties(5) High-Risk Processes• Annual risk analysis• Competency assessments

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) 20: VA Northwest Health Network in Vancouver, Washington, 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; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this unannounced review during concurrent virtual site visits of VISN 20 facilities.The executive leaders had worked together for approximately one month at the time of the OIG virtual review. The VISN office and leaders’ selected employee satisfaction survey averages were generally better than VHA averages, with the exception of the Deputy Network Director and Chief Medical Officer’s scores. Overall, VISN leaders appeared to maintain an environment where employees felt safe bringing forth issues and concerns. Patient experience survey scores were similar to or better than VHA averages. Leaders were knowledgeable within their scope of responsibilities about selected data used in Strategic Analytics for Improvement and Learning models and should continue to sustain and improve performance.The OIG issued four recommendations for improvement in two areas:(1) Medical Staff Credentialing• Credentials file review and approval for physicians with potentially disqualifying licensure actions(2) High-Risk Processes• Sharing of VISN-led facility reusable medical equipment inspection results with executive leaders• Posting of inspection results to the reusable medical equipment SharePoint site• Oversight of facility corrective action plan development and action item tracking