Federal Reports

In this Agency Financial Report (AFR), we discuss CIGIE’s fiscal year (FY) 2019 accomplishments in carrying out its mission and performance plan goals; provide the independent auditor’s report regarding CIGIE’s financial statements as of September 30, 2019; and highlight the work of CIGIE’s Executive Council, eight standing committees, and individual members on cross-cutting issues affecting Federal departments, agencies, and Offices of Inspector General.The financial audit was performed by Harper, Rains, Knight & Company (HRK); the report reflects financial statements that present fairly the financial position of the organization. This year’s report also identified one material weakness and one significant deficiency, both of which are being proactively addressed.

What We Looked AtWe contracted with the independent public accounting firm Allmond & Company, LLC, to audit the National Transportation Safety Board’s (NTSB) financial statements as of and for the fiscal years ended September 30, 2019, and September 30, 2018, and to report on internal control over financial reporting and compliance with laws and other matters. The contract requires the audit to be performed in accordance with U.S. generally accepted Government auditing standards, Office of Management and Budget audit guidance, and the Government Accountability Office’s and Council of the Inspectors General on Integrity and Efficiency’s Financial Audit Manual. In connection with the contract, we performed a quality control review of Allmond’s report dated November 6, 2019, and related documentation, and inquired of its representatives. What We FoundOur quality control review disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards. RecommendationsAllmond made no recommendations.

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This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Carl Vinson 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 was not stable, with vacancies for director and chief of staff. Employee satisfaction and patient experience surveys results were similar to or lower than VHA averages. The OIG’s review of institutional disclosures identified an opportunity to ensure timely notification to patients and accurately maintain information and data on disclosures. The leaders should continue to take actions to improve care and performance of measures contributing to the Strategic Analytics for Improvement and Learning “3-star” and community living center “1-star” quality ratings. The OIG issued 22 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary utilization management data reviews • Root cause analyses • Resuscitative episode reviews (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Privileging action reporting to National Practitioner Data Bank (3) Environment of Care • Panic alarm testing (4) Medication Management • Reconciliation of dispensing and return of stock • Verification of hard copy prescriptions • Monthly controlled substances inventory verification • Medication override process (5) Mental Health • Communication of issues, services, and initiatives to leadership • Military sexual trauma training (6) Geriatric Care • Patient/caregiver education and understanding of medications (7) Women’s Health • Designated women’s health medical director/clinical champion • Women Veterans Health Committee processes • Cervical cancer screening data tracking process • Patient notification of abnormal results (8) High-risk Processes • Backup call schedule for urgent care center providers