An official website of the United States government
Here's how you know
Official websites use .gov
A .gov website belongs to an official government organization in the United States.
Secure .gov websites use HTTPS
A lock (
) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.
Brought to you by the Council of the Inspectors General on Integrity and Efficiency
What We Looked AtThe Pipeline and Hazardous Materials Safety Administration (PHMSA) aims to protect people and the environment by advancing the safe transportation of energy and other hazardous materials. An essential element of PHMSA’s safety mission is its underlying safety culture—the organization’s safety-related values and behaviors. A positive safety culture is essential to any organization that directly or indirectly addresses high-hazard risks, such as the regulatory agencies of DOT. We initiated this audit to help Agency leaders make informed decisions about their organizational safety culture and focused on PHMSA because it had publicly identified fostering a positive safety culture as a strategic goal. The first part of this report is an assessment of PHMSA’s safety culture. The second part evaluates PHMSA’s efforts to foster a positive safety culture as it carries out its mission and other responsibilities. What We FoundWhile PHMSA exhibits several indicators of a positive safety culture, we also found opportunities to further enhance its efforts. For example, many employees have positive perceptions of their immediate supervisors and the Agency’s impact on industry safety. However, some non-supervisors indicated that they do not trust management to share information and perceive that industry and PHMSA are not sufficiently separate, which may impact the way employees share concerns with management. PHMSA also developed a number of safety culture–related initiatives but did not always complete or document its actions. For example, in 2015, PHMSA allocated $1.5 million for safety culture planning and, over the next 4 years, expended one-third of that amount. Additionally, no one individual is focused wholly on fostering a positive safety culture at all times, including during changes of administrations. While most employees believe PHMSA’s leadership is committed to safety, some express doubt about the leadership’s commitment to fostering a positive safety culture. Our RecommendationsPHMSA concurred with our two recommendations to enhance its efforts to foster a positive safety culture. Accordingly, we consider them resolved but open pending completion of the planned actions.
The VA Office of Inspector General (OIG) conducted a healthcare inspection at the facility to evaluate allegations related to a thoracic surgeon’s surgical complications including patient deaths and misrepresentations of operative note documentation and the facility’s inappropriate reporting of the thoracic surgeon’s complication rate.The surgeon, board certified in thoracic and cardiac surgery, began clinical practice in 2009, started working at the facility in 2013 as a staff thoracic surgeon, and was selected to become Chief of Surgery in July 2014.On November 9, 2017, the OIG received a complaint about the surgeon’s competency and quality of care in five patient cases. The OIG consulted with a non-VA thoracic surgeon, who reviewed the care of the five patients as well as 19 patient cases from a previous OIG evaluation.The non-VA consultant identified quality of care concerns with 16 of the 24 patient cases. The facility completed external management reviews and found five cases of concern. In February 2019, the surgeon was reassigned to a nonclinical care setting. Veterans Health Administration (VHA) and Veterans Integrated Service Network leaders established a panel of VHA cardiothoracic surgeons who reviewed 22 of the 24 cases evaluated by the non-VA consultant as well as other, additional cases. In December 2019, the panel determined that the surgeon delivered thoracic surgical care within quality expectations and the surgeon resumed patient care.The OIG did not substantiate that the facility failed to appropriately report surgical errors and complications. The OIG made five recommendations to the Under Secretary for Health related to a thoracic specialty leader, operative documentation, the National Surgery Office’s surgery assessments, and peer review processes. The OIG made an additional five recommendations to the Facility Director related to operative documentation, professional communications, Surgical Work Group oversight, privileging, and institutional disclosures.
Marc Hoang, a Pharmacist based in West Covina, California, pleaded guilty in United States District Court, Central District of California, on October 26, 2020, to making a false statement related to a health care fraud investigation. Our investigation found that Hoang knowingly and willfully made a materially false and fraudulent statement on a Drug Enforcement Administration (DEA) form. Hoang submitted the form to the DEA to renew the controlled substances registration for his former pharmacy. On the form, Hoang represented that he was the person who distributed the controlled substances and was the officer and point of contact for the pharmacy, when in fact, he was not.In this same investigation, Navanjun Grewal, a Plastic and Reconstructive Surgeon based in Beverly Hills, California, pleaded guilty in United States District Court, Central District of California, on January 13, 2021, to making and using a false document and to obstruction of a federal audit. Our investigation found that Grewal created false and fraudulent patient files in response to an audit request regarding prescriptions for compounded medications that were submitted for reimbursement.Both defendants will be sentenced at a future date.
