Federal Reports

This Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered by Veterans Health Administration facilities. The report covers key processes that are associated with promoting quality care, and focuses on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma (MST) Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Operations and Management of Emergency Departments and Urgent Care Centers.The Office of Inspector General (OIG) noted that 88 percent of facility leaders were assigned permanently at the 43 VA facilities visited in fiscal year 2019. These facility leaders generally appeared engaged in quality activities, felt supported by network leaders, were aware of employee/patient satisfaction improvement efforts, and actively addressed recommendations for improvement. However, the OIG found opportunities for some facilities to improve their Strategic Analytics for Improvement and Learning ratings.The OIG issued 32 recommendations for improvement across eight areas:(1) Quality, Safety, and Value• Peer review processes• Cardiopulmonary resuscitation committee processes(2) Medical Staff Privileging• Focused and ongoing professional practice evaluations(3) Environment of Care• Emergency resource and asset inventory review(4) Medication Management• Controlled substances inspection report review• Limitations to perform balance adjustments• Monthly physical controlled substances inspections• Override report review(5) Mental Health• MST issues, services, and initiatives communicated to leaders• Mandatory MST training(6) Geriatric Care• Patient and/or caregiver education• Medication reconciliation(7) Women’s Health• Committee membership and activities• Cervical cancer screening data tracking(8) High-Risk Processes• Operating hours, staffing, support services, and directional signage

Our objective was to (1) determine whether the Social Security Administration (SSA) made payments to beneficiaries and representative payees who were deceased according to Ohio Department of Health vital records and (2) identify non-beneficiaries in the State files whose death information did not appear in Agency records.

Florida school districts participating in Medicaid as providers certify quarterly that they have used non-Federal education funds for school-based services.Prior Office of Inspector General (OIG) audits identified significant overpayments to school districts for school-based services. In those audits, we recommended that the States refund to the Federal Government the unallowable reimbursement that was claimed for the Medicaid school-based services. We performed this audit in Florida to determine whether the unallowable reimbursements we identified in other States also occurred in Florida.Our objective was to determine whether Florida claimed Federal Medicaid reimbursement for school-based services in accordance with Federal and State requirements.

The OIG investigated allegations that a company fraudulently altered a purchase order (PO) that the National Park Service (NPS) awarded for the replacement of two fuel pumps at Great Smoky Mountains National Park. The company also allegedly then issued the altered PO to a second company to perform the work.We found that Kentey Fielder, owner of the first company, falsely represented himself to a second company as an NPS employee and emailed that second company two altered POs reflecting the second company as the primary contractor on the NPS fuel pump project. On the basis of these fraudulent POs, the second company then performed the work. The NPS subsequently paid Fielder under the legitimate PO, but Fielder never paid the second company for the equipment or labor it provided.Fielder pleaded guilty to one count in violation of 18 U.S.C. § 1343, Wire Fraud, and was subsequently sentenced to 3 years of probation with an additional condition of 8 months of home detention. He was also ordered to pay restitution totaling $12,687.62 and was debarred from participation in Federal procurement and nonprocurement programs.

Audit of the CFTC Customer Protection Fund Financial Statements (Fiscal Year 2020)

We audited the Tennessee Valley Authority's (TVA) purchasing card (P-Card) usage to determine if personnel complied with TVA's P-Card policies and procedures. Our audit scope included approximately $79.8 million in transactions occurring from October 1, 2017, through September 30, 2019. Our audit found multiple instances where TVA personnel did not comply with requirements in TVA's P-Card policies and procedures. Specifically, we found (1) some approving officials were not performing their review duties properly, (2) split transactions occurred, (3) disallowed and questionable (nonbusiness expense) transactions occurred, (4) only 25 percent of TVA's cardholders and approving officials completed the required annual P-Card training at least once, (5) periodic audits of P-Card transactions by Supply Chain were not performed, and (6) certain potentially fraudulent transactions by one cardholder had not been identified due to inadequate reviews of the cardholder statements. OIG Investigations subsequently found evidence the cardholder had used the P-Card to make several monthly rental payments to the apartment complex where the cardholder lived. In addition to those areas of noncompliance listed above, we found P-Cards were being used without determining if sources the Supply Chain and Financial Services Standard Programs and Processes rank ahead of the P Card in its hierarchy were available. We made 12 recommendations to TVA management to strengthen controls and help improve compliance with the P-Card policies by (1) implementing additional procedures and monitoring activities and (2) clarifying and updating the policies and related training. TVA management provided actions they plan to take to address each of our recommendations.