Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the John D. Dingell VA Medical Center (facility) to evaluate allegations of inaccurate complete blood count (CBC) with differential results and reporting, and a laboratory supervisor not passing a proficiency test. The OIG identified concerns regarding quality assurance processes and laboratory leaders’ response, which were not in compliance with VHA Directive 1106, Pathology and Laboratory Medicine Service and VHA Directive 1050.01(1), VHA Quality and Patient Safety Programs. 

The OIG substantiated eight medical technologists (technologists) missed or under reported blast cells, leading to inaccurate CBC with differential results for a patient. The OIG did not identify adverse clinical outcomes. 

Laboratory leaders did not implement a quality assurance process to ensure the accuracy of CBC with differential results. Further, none of the technologists were informed of the inaccurate readings, precluding mitigation of errors. Pathologists completed the OIG-requested retrospective review of readings, but the OIG remains concerned that misreads may continue without sustained oversight.

Laboratory leaders, including the quality management technologist, and patient safety managers, did not ensure corrective actions were timely implemented or tracked. Factors contributing to delayed completion of corrective actions and unresolved patient safety risks included conflicting interpretations of the quality management technologist’s responsibilities and laboratory leaders not following a reporting policy. 

The OIG substantiated a supervisor did not pass a blood bank proficiency test in summer 2024, leading to the suspension of blood bank crossmatch testing services. However, laboratory leaders constructed a contingency plan and completed requirements to resume services within a week.

The Facility Director concurred with the OIG’s five recommendations related to communicating errors to technologists, patient safety staff’s monitoring of action plans, clarification of the quality management technologist’s role, oversight of accuracy for CBC results, and laboratory leaders not following a reporting policy.

The Government Charge Card Abuse Prevention Act of 2012,as implemented by Office of Management and Budget (OMB) Circular A-123, Appendix B, requires the Office of Inspector General (OIG) to conduct periodic risk assessments of agency purchase and travel card programs. OIG conducts these assessments to identify and analyze the risk of illegal, improper, or erroneous purchases and payments and to determine the appropriate scope, frequency, and number of periodic audits of these programs.  

To assess risk associated with the Department of State’s (Department) purchase card program, OIG reviewed the Department’s FY 2024 purchase card data and concluded that the risk of illegal, improper, or erroneous purchases and payments within the Department purchase card program was “medium.” OIG based its conclusion on the purchase card program’s size, internal controls, training, previous audits, violation reports, and observations from OIG’s Office of Investigations (INV).  

With respect to the criterion related to previous audits, OIG audited the Department’s purchase card program and issued a report in March 2019. The five recommendations offered in that report have been implemented and closed. Therefore, OIG is not recommending that an audit of the Department’s purchase card program be included in its FY 2027 work plan. However, OIG encourages the Department’s purchase card manager to continue prudent oversight of the purchase card program to ensure that internal controls intended to safeguard taxpayer funds are fully implemented and followed by Department purchase card holders. 

The Government Charge Card Abuse Prevention Act of 2012, as implemented by Office of Management and Budget (OMB) Circular A-123, Appendix B, requires the Office of Inspector General (OIG) to conduct periodic risk assessments of agency purchase and travel card programs. OIG conducts these assessments to identify and analyze the risk of illegal, improper, or erroneous purchases and payments and to determine the appropriate scope, frequency, and number of periodic audits of these programs. 

To assess risk associated with the purchase card program at the International Boundary and Water Commission, United States and Mexico, U.S. Section (USIBWC), OIG reviewed USIBWC’s FY 2024 purchase card data and concluded that the risk of illegal, improper, or erroneous purchases and payments within the USIBWC purchase card program was “low.” OIG based its conclusion on the USIBWC purchase card program size, internal controls, training, previous audits, and observations from OIG’s Office of Investigations (INV). Because OIG concluded that risk to the purchase card program was “low,” 

OIG is not recommending that an audit of the USIBWC purchase card program be included in OIG’s FY 2027 work plan. However, OIG encourages USIBWC officials to continue prudent oversight of the purchase card program and ensure that internal controls intended to safeguard taxpayer funds are fully implemented and followed by USIBWC purchase card holders.

The Government Charge Card Abuse Prevention Act of 2012, as implemented by Office of Management and Budget (OMB) Circular A-123, Appendix B, requires the Office of Inspector General (OIG) to conduct periodic risk assessments of agency purchase and travel card programs. OIG conducts these assessments to identify and analyze the risk of illegal, improper, or erroneous purchases and payments and to determine the appropriate scope, frequency, and number of periodic audits of these programs.

To assess risk associated with the Department of State’s (Department) travel card program, OIG reviewed the Department’s FY 2024 travel card data and concluded that the risk of illegal, improper, or erroneous purchases and payments within the Department’s travel card program was “medium.” OIG based its conclusion on the travel card program’s size, internal controls, training, previous audits, and observations from OIG’s Office of Investigations (INV).  

Although OIG concluded that risk to the travel card program is “medium,” OIG plans to audit the Department’s travel card program during FY 2026. Therefore, OIG is not recommending that an audit of the Department’s travel card program be included in OIG’s FY 2027 work plan. OIG encourages Department officials to continue prudent oversight of the travel card program to ensure that internal controls intended to safeguard taxpayer funds are fully implemented and followed by Department travel card holders. 

The Government Charge Card Abuse Prevention Act of 2012, as implemented by Office of Management and Budget (OMB) Circular A-123, Appendix B, requires the Office of Inspector General (OIG) to conduct periodic risk assessments of agency purchase and travel card programs. OIG conducts these assessments to identify and analyze the risk of illegal, improper, or erroneous purchases and payments and to determine the appropriate scope, frequency, and number of periodic audits of these programs.

To assess risk associated with the purchase card program at the U.S. Agency for Global Media (USAGM), OIG reviewed USAGM’s FY 2024 purchase card data and concluded that the risk of illegal, improper, or erroneous purchases and payments within the USAGM purchase card program was “low.” OIG based its conclusion on USAGM’s purchase card program size, internal controls, training, previous audits, and observations from OIG’s Office of Investigations (INV).

Because OIG concluded that risk to the purchase card program was “low,” OIG is not recommending that an audit of the USAGM purchase card program be included in OIG’s FY 2027 work plan. However, OIG encourages USAGM officials to continue prudent oversight of the purchase card program and ensure that internal controls intended to safeguard taxpayer funds are fully implemented and followed by USAGM purchase card holders.