Federal Reports

The VA Office of Inspector General (OIG) conducted an inspection in response to multiple allegations related to Ophthalmology Clinic management, quality of care, oversight, medication management, and facility leaders’ failures at the VA Central Iowa Health Care System (facility) in Des Moines. The OIG team did not substantiate that the facility hired a new physician right out of residency to be Chief of Ophthalmology, there was a lack of appropriate supervision of ophthalmology residents, the quality of cataract surgeries decreased while the number of complications increased, cataract surgery outcomes were not reviewed by an oversight group, and surgery managers and facility leaders were told about complications and other concerns and did not take action. Facility audit report findings identified inappropriate storage and labeling of medications in the Ophthalmology Clinic. The OIG found facility leaders took actions to resolve the findings. The OIG identified deficits in Ophthalmology Clinic staff members’ knowledge and use of the required patient safety event reporting system. The OIG also identified issues with the management and impact of ongoing personnel conflicts within the Ophthalmology Clinic. Leaders at multiple levels had difficulty managing the impact of interpersonal conflicts in the Ophthalmology Clinic that adversely affected the culture of the clinic. The OIG made four recommendations to the Facility Director related to training staff on reporting patient safety incident events and close calls, entering patient safety events and close calls into the Joint Patient Safety Reporting system, addressing the Ophthalmology Clinic culture, and the oversight and management of the Ophthalmology Clinic.

John Kosloski, a chiropractor based in Dolton, Illinois, pleaded guilty in U.S. District Court, Northern District of Illinois, to Health Care Fraud on November 3, 2020. Our investigation found that Kosloski submitted fraudulent medical claims to Amtrak insurance providers for services that were not rendered. Kosloski obtained personal identifying information of former Amtrak employees or those of their dependents, in exchange for cash kickbacks. As a result of this scheme, Amtrak incurred a loss of approximately $504,374. Kosloski’s sentencing is pending.

An Amtrak trackman/watchman based in Chicago, Illinois, was terminated from employment on November 3, 2020, following his administrative hearing. Our investigation found that the former employee failed to report an arrest and conviction for a DUI while employed with the company. We also found that the former employee violated company policy by signing out a company vehicle when his driver’s license was suspended, and that he bid for a position which required a valid driver’s license for which he submitted fraudulent records. Further, the former employee was dishonest with our agents during his interview.

This is the audit of the Arts Endowment's information technology systems security. Due to security concerns, this report is not published on the internet. You can obtain a copy of this report through a freedom of information act request at the following link: https://www.arts.gov/freedom-information-act-guide.

We found violations of U.S. Immigration and Customs Enforcement (ICE) detention standards undermining the protection of detainees’ rights and the provision of a safe and healthy environment. Although the Howard County Detention Center (HCDC) generally complied with ICE detention standards regarding communication, it did not meet the standards for detainee searches, food service, and record requirements for segregation and medical grievances. We determined HCDC excessively strip searched ICE detainees when leaving their housing unit to attend activities within the facility, in violation of ICE detention standards and the facility’s own search policy. In addition, HCDC failed to provide detainees with two hot meals per day, as required. For those in segregation, HCDC did not document that detainees received three meals per day and daily medical visits. Further, HCDC did not properly document the handling of detainee medical grievances. We made two recommendations to ICE’s Executive Associate Director of Enforcement and Removal Operations (ERO) to ensure the Baltimore ERO Field Office overseeing HCDC addresses identified issues and ensures facility compliance with relevant detention standards. ICE concurred with both recommendations and is implementing a corrective action plan to address the concerns we identified.