Federal Reports

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

Following Hurricane Maria, FEMA did not maximize the use of advance contracts to address identified capability deficiencies and needs in Puerto Rico. Specifically, we identified 49 of 241 new contracts issued in the aftermath of Hurricane Maria for the same goods or services covered by existing advance contracts. We attributed FEMA’s limited use of advance contracts to its lack of a strategy and documented planning process for ensuring maximum use of advance contracts. Further, FEMA did not maintain contract files in accordance with Federal acquisition regulations and departmental or its own policy. This occurred because FEMA’s Office of the Chief Procurement Officer did not have controls in place to ensure contract personnel follow Federal regulations and departmental or its own internal policy. As a result, FEMA’s ability to hold contractors accountable for deliverables is hindered if contract files are not easily located. We made four recommendations to help FEMA improve its strategy for advance contracts, its process for identifying capability needs and gaps, and its contract file management practices. FEMA concurred with all four recommendations and described corrective actions it plans to take.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that the Associate Director for Patient Care Services endangered patient safety by placing an unqualified leader as the Acting Chief of Sterile Processing Services (SPS) at the facility. The OIG did not substantiate that the detailed Acting Chief endangered patient safety. Facility leaders based incumbent selection on leadership experience and the individual’s workload, which the detailed Acting Chief had. The OIG reviewed issue briefs submitted during the time of the detail and found no patients were harmed. Facility leaders failed to comply with a 2009 memorandum requiring complexity Level 1 and 2 facilities to have an SPS assistant chief position. Facility leaders failed to ensure a reliable process was in place for identifying changes in manufacturer’s instructions. Moreover, from 2011 to 2017, SPS staff reassembled the arthroscopes and cystoscopes prior to sterilization contrary to the manufacturer’s instructions. However, once the issue was identified, the facility, Veterans Integrated Service Network, and Veterans Health Administration leaders took appropriate action to address the problem, evaluated associated risk, consulted with the required experts, and decided based on their risk analysis that patient exposure risk was minimal and no further actions were needed. A possible reason for the facility’s failure to identify the change to the manufacturer’s instructions was a series of acting and permanent chiefs of SPS. This lack of stable SPS leadership also contributed to the failure to review and update SPS staff competencies. The OIG made three recommendations relating to staffing, compliance with manufacturer’s instructions, and competencies.