Federal Reports

What We Looked AtThe Federal Aviation Administration (FAA) Administrative Services Franchise Fund is a Government-run, fee-for-service organization that aims to foster competition, increase efficiency, and reduce costs across the Federal Government. The Fund has six service organizations and reported $480 million in annual revenues in 2018. As required by the FAA Reauthorization Act of 2018, our office initiated an audit to assess FAA’s management and oversight of the Fund’s operations and activities. Specifically, we looked at the Fund’s history, intended purpose, and objectives; conformance to generally accepted accounting principles; and conformance to Federal policies and other guidelines. What We FoundThe Fund’s six service organizations serve multiple types of customers; by law, they are required to receive payment in advance. While the Fund’s annual revenues reflect increases in its services and customers, we found weaknesses in its internal controls. For example, the Fund does not track inventory age; as such, we could not determine if the inventory value, reported to be $656 million in 2018, had been overstated. Fund officials also do not conduct adequate oversight of the financial operations. For example, we found $2.6 million in unexpended funds that should have been returned to customers; we project the total unreturned amount to be $26 million of $338 million in unexpended funds. In addition, if they are not paid in advance, some service organizations use operating reserves to pay for the costs of providing services, contrary to law. Most of them do not fully comply with requirements for capital reserve plans—increasing the risk that funds could be mismanaged. Still, FAA is changing the Fund’s governance structure, which might allow it to measure whether the Fund is receiving adequate oversight and stability. However, FAA could do more to address customer concerns regarding transparency and to avoid the risk of improperly obligating funds. Enhancing financial-related internal controls is key to ensuring the Franchise Fund functions as Congress intended. Our RecommendationsWe made 13 recommendations to help FAA strengthen its management and oversight of the Franchise Fund. FAA fully concurred with recommendations 3 through 13, but did not concur with recommendations 1 and 2. We have asked the Agency to reconsider its position.

Enacted in January 2016, the Grants Oversight and New Efficiency Act requires Federal agencies to report to Congress and the Department of Health and Human Services on open grant and cooperative agreement awards whose periods of performance have been expired for at least 2 years, and take appropriate action to close them. The act also requires the Inspector General of each agency with over $500 million in annual grant funding, such as the Department of Transportation (DOT), to conduct a risk assessment to determine whether an audit or review of the agency’s grant close-out process is warranted. Our risk assessment of DOT’s grant closeout process did not detect a level of risk that warrants an audit or review of the process at this time. However, we will continue to monitor this area and may conduct future audits as appropriate.

An Amtrak Assistant Conductor in Pontiac, Michigan, was terminated from employment on November 12, 2019, following an administrative hearing for violating company policy. Our investigation found that the employee submitted false documentation and made false and misleading statements regarding his claim that he sustained a work-related injury. Additionally, the employee was not truthful when we interviewed him during this investigation.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the VA Manila Outpatient Clinic, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma 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: Emergency Department and Urgent Care Center Operations. The facility’s leaders had been working together for two years, although the clinic manager (director) had served in the position for many years. The facility’s leadership team appeared relatively stable; however, a new director was scheduled to assume duties one week after the OIG’s on-site visit. Selected employee satisfaction survey results, except that for the director regarding servant leadership, indicated that leaders were engaged and promoted a culture of safety where employees feel safe bringing forward issues and concerns. The selected patient experience survey scores for facility leaders were better than the VHA average. Additionally, the OIG reviewed accreditation agency findings, sentinel events, and disclosures of adverse patient events and did not identify any substantial organizational risk factors. However, the impact of political unrest in the Philippines may affect access to care and safety of veterans and staff. The OIG issued seven recommendations for improvement: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluations (2) Controlled Substances Inspections • Pharmacy inspection inventory counts (3) Military Sexual Trauma (MST) Follow-up and Staff Training • Communicating the status of MST services with leaders • Tracking MST-related data • Completing timely diagnostic treatment evaluations (4) Antidepressant Use among the Elderly • Patient/caregiver education on newly prescribed medications • Medication reconciliation

The VA Office of Inspector General (OIG) evaluated the oncology service staff’s adherence to the facility’s psychosocial distress screening standard operating procedure in the care of two patients who died by suicide, and facility leaders’ response to the root cause analyses following the two patients’ deaths. Facility oncology service staff demonstrated compliance with psychosocial distress screening standard operating procedures. However, the OIG was unable to determine if a mental health evaluation completed prior to one of the patients leaving the clinic would have changed the patient’s outcome. Completion of a mental health evaluation may have identified additional risk factors and provided opportunity for suicide prevention interventions prior to the patient leaving the clinic. The National Comprehensive Cancer Network standards of care state a patient should be screened at the initial visit and ideally at every visit. Facility oncology service nursing staff were unclear about when to administer the psychosocial distress thermometer, a self-report tool that evaluates a patient’s distress level, and therefore, administered the tool at every visit. Thus, nursing practice in the facility oncology service exceeded the facility standard operating procedure requirements and provided the National Comprehensive Cancer Network ideal standard of care. The alignment of the standard operating procedure with the ideal standard and current practice is critical to ensure clear guidance to staff regarding the completion of the psychosocial Distress Thermometer. The facility’s Patient Safety Manager did not monitor progress toward root cause analysis action item completion. Following the OIG team’s expressed concern about this deficiency, the Patient Safety Manager implemented a tracking tool that same month. The OIG identified one additional concern. After a patient’s death by suicide in 2017, the Acting Suicide Prevention Coordinator did not complete a Suicide Behavior Report or Behavioral Health Autopsy, as required by Veterans Health Administration.