Federal Reports

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

Over the past 20 years, digital diversion of communication, growth in ecommerce, changing customer needs and expectations, and new sources of competition have transformed the mail and parcel industry. In this white paper, the OIG researched public and private organizations with similarities to the Postal Service that managed to adapt and succeed in other disrupted markets. We highlighted specific insights from these case studies that can be informative for the Postal Service as it sets its strategies for the future.

We conducted a performance audit of two National Endowment for the Arts (Arts Endowment) Partnership awards issued to the Washington State Arts Commission (ArtsWA). Based on our review, we determined ArtsWA generally met the financial and compliance requirements in the award documents. However, we identified some areas requiring improvement. For instance, we found that ArtsWA: included $31,000 in unallowable cost share on its Federal Financial Reports (FFRs); included $19,458 in unallowable entertainment costs on its FFRs; did not notify all subrecipients of Federal subaward management requirements; and did not verify potential vendors were eligible to receive Federal funds. We believe the evidence obtained during the audit provides a reasonable basis for our findings and conclusions based on our audit objectives. We are questioning $50,458 ($31,000 plus $19,458) in unallowable costs. We also made six recommendations to address the audit findings -- four to ArtsWA and two to the Arts Endowment.

The VA Office of Inspector General (OIG) reviewed allegations referred by Chairman Mark Takano, House Committee on Veterans’ Affairs, regarding deficiencies in the mental health care provided at the Ralph H. Johnson VA Medical Center (facility) to a high risk for suicide patient who died by suicide.The OIG did not substantiate that service agreement procedures resulted in inadequate psychiatric monitoring or delayed psychiatric care or that facility staff delayed placement of the patient’s high risk for suicide patient record flag.The OIG found that staff did not adequately evaluate the patient’s condition when reviewing the patient’s high-risk status. Facility staff did not assign a Mental Health Treatment Coordinator (MHTC) prior to discharge or establish a facility MHTC policy, as required. The Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment (REACH VET) provider did not outreach the patient, as required.Facility staff did not comply with Veterans Health Administration suicide risk assessment procedures and did not notify facility leaders or suicide prevention staff of the patient’s death by suicide.The OIG made five recommendations to the Facility Director related to high risk for suicide patient record flag reviews, MHTC assignment, REACH VET program requirements, suicide risk assessment, and staff notification of patients’ death by suicide.