Federal Reports

The OIG investigated an allegation that U.S. Geological Survey (USGS) senior leaders may not have been forthcoming to the USGS Director about their knowledge of violations identified by the Nuclear Regulatory Commission (NRC). In 2018, the NRC issued the USGS a civil penalty for infractions identified during an inspection of a USGS test reactor facility. Reportedly, USGS senior leaders denied they had any knowledge of the matter at the time, and the USGS requested the OIG’s assistance in determining whether information had been communicated to them by their staff.We did not find evidence showing that senior leaders withheld information on the issue. We did find that for approximately 1 month, the two staff members involved corresponded exclusively with one another and the NRC about the violations before informing their superiors and others at the USGS in mid-October 2018. One of the staff members subsequently left the Department and the other changed positions.

The U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA), did not resolve audit recommendations in a timely manner during Federal fiscal years (FYs) 2015 and 2016. SAMHSA resolved 104 of the 292 audit recommendations that were outstanding during FYs 2015 and 2016. However, it did not resolve any of the 104 recommendations within the required 6-month resolution period. In addition, as of September 30, 2016, SAMHSA had not resolved 188 audit recommendations that were past due for resolution. These 188 past-due recommendations were procedural in nature; none of them involved dollar amounts such as recommended disallowances.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations of an inadequate response to a Code Orange and patient safety concerns for a missing patient at the facility. The OIG substantiated that the patient went missing from the facility in spring 2018. Staff contacted the covering physician, who determined that the patient was at risk; however, the physician did not document the assessment until after receiving a call from a facility leader. Staff did not comply with the facility policy for patient identification and the facility lacked a policy addressing look-alike or soundalike names. As a result, staff misidentified the wrong patient as missing and approximately two hours elapsed before staff corrected the error. Although the administrative officer of the day did not comply with policy to contact outside hospitals and shelters, unit staff and social workers made multiple calls and located the patient at a community hospital five days after being missing. The facility submitted issue briefs, conducted a Code Orange debrief, and later completed a root cause analysis. The facility’s incident report did not address the misidentified patient, and the fact finding did not review all personnel involved in the event. Prior to the event, staff received training on managing missing and wandering patients and the facility distributed a Code Orange visual aid for reference. In response to the event, VA police began conducting annual drills, and the unit nurse managers held a staff meeting and daily huddles to reinforce the importance of following the Code Orange protocols. In addition, the nurse managers introduced time-out huddles prior to calling a Code Orange to ensure the correct identity of the missing patient. The OIG made three recommendations related to patient identification, documentation, and understanding duties and responsibilities.

U.S. Postal Service retail associates (RA) can use the Retail Systems Software’s No Sale administrative function to open the cash drawer, typically to exchange higher value currency for lower value currency denominations. The RA must make three selections in the system to choose the No Sale option; therefore, selection of the No Sale option is not accidental and gathers suspicion when done with frequency. Extremely high No Sale transactions may indicate dubious trends or behaviors. The objective of this audit was to identify opportunities to enhance controls used by headquarters organizations to monitor No Sale transactions.