Federal Reports

The Corporation for National and Community Service, Office of Inspector General (CNCS-OIG) presents its Fall 2019 Semiannual Report, covering the six-month period of April 1, 2019 – September 30, 2019.

The Department of Veterans Affairs, Office of Inspector General (OIG) issued the Semiannual Report to Congress (SAR) April 1 – September 30, 2019. The SAR summarizes the results of OIG oversight, provides statistical information, and lists all reports issued April 1 – September 30, 2019. During this reporting period, OIG audits, investigations, inspections, evaluations, and other reviews identified over $1.81 billion in monetary benefits for a return of $24 for every dollar invested in OIG oversight. Also during this reporting period, OIG issued 161 reports and publications on VA programs and operations, made 661 recommendations, and conducted investigations that led to 131 arrests.

The OIG investigated an allegation that a Bureau of Land Management (BLM) employee may have accessed and viewed child pornography on a Government computer on multiple occasions.We found that the employee accessed and viewed adult pornography on the Government computer while inside a Government office but found no evidence the employee viewed child pornography. The employee admitted viewing adult pornography on multiple occasions but denied any involvement with child pornography. Accessing and viewing pornography on a Government computer violates DOI policy; the employee said he knew that DOI policy prohibited his actions.The employee retired during our investigation.

DHS did not have the Information Technology (IT) system functionality needed to track separated migrant families during the execution of Zero Tolerance. U.S. Customs and Border Protection (CBP) adopted various ad hoc methods to record and track family separations, but this practice introduced widespread errors. These conditions persisted because CBP did not address known IT deficiencies before the Zero Tolerance Policy was implemented in May 2018. DHS also did not provide adequate guidance to personnel responsible for executing the policy. Because of the IT deficiencies, we could not confirm the total number of families DHS separated during the Zero Tolerance period. DHS estimated Border Patrol agents separated 3,014 children from their families while the policy was in place. DHS also estimated it completed 2,155 reunifications, although this effort continued on for seven months beyond the July 2018 deadline for reunifying children with their parents. However, we conducted a review of DHS data during the Zero Tolerance period and identified 136 children with potential family relationships that were not accurately recorded by CBP. In a broader analysis of DHS data between the dates of October 1, 2017 to February 14, 2019, we identified an additional 1,233 children with potential family relationships not accurately recorded by CBP. Without a reliable accounting of all family relationships, we could not validate the total number of separations, or the completion of reunifications. Although DHS spent thousands of hours and more than $1 million in overtime costs, it did not achieve the original goal of deterring “Catch-and-Release” through the Zero Tolerance Policy. Moreover, the surge in apprehended families during this time period resulted in children being held in CBP facilities beyond the 72-hour legal limit. The Department concurred with all five report recommendations.

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care at the Manchester VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Care; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results; and High-Risk Processes: Emergency Department/Urgent Care Center Operations. The facility’s leadership team is generally stable and has active engagement with employees and patients as evidenced by high satisfaction scores. Leaders supported efforts related to safety and quality care; however, the OIG identified a substantial organizational risk—the lack of available support services. Specifically, the OIG is concerned with the urgent care clinic’s lack of access to on-site support services during evenings, nights, weekends, and holidays and limited availability of staff to provide consistent and immediate advanced airway support for cardiopulmonary resuscitation events. The leaders were knowledgeable about Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to improve care and performance of quality of care metrics contributing to current SAIL ratings. The OIG issued 17 recommendations for improvement: (1) Quality, Safety, and Value • Review of literature for root cause analyses (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • Maintenance of a clean and safe environment (4) Mental Health • Military sexual trauma referrals, training, and communication of initiatives (5) Geriatric Care • Justification for medication and reconciliation • Caregiver/patient medication education (6) Women’s Health • Communication of abnormal results to patients (7) Emergency Departments and Urgent Care Center Operations • Urgent Care Center registered nurse staffing • Backup call schedule for Urgent Care Center providers • Availability of support services