Federal Reports

FEMA’s December 2017 Eligibility Determination of Cobra contract costs for its Public Assistance (PA) program was unsound. Federal regulations and FEMA policy require all costs claimed under the PA program to be necessary and reasonable to accomplish the work properly and efficiently. FEMA conducted an analysis of the Cobra contract rates and determined that contract costs were reasonable and eligible for the PA program. However, FEMA did not evaluate the actual time and materials costs incurred under the contract for reasonableness, and its analyses of the contract rates for labor, equipment, and other costs were not always logical, complete, and supported. As a result, FEMA approved a PA grant and reimbursed millions of dollars for Cobra contract costs based on an unsound eligibility determination. We made one recommendation that, when implemented, will correct the deficiencies with FEMA’s evaluation of cost reasonableness of Cobra contract costs. FEMA concurred with our recommendation and described the corrective actions necessary to address the issues we identified in our report. Specifically, FEMA will update its October 2018 Public Assistance: Reasonable Cost Evaluation Job Aid and the Public Assistance Program and Policy Guide to include additional guidance specific to Time and Materials contracts. FEMA is also conducting additional analyses of the actual time and material costs to determine the reasonability and eligibility of Cobra contract costs for PA funding.

The Office of Inspector General (OIG) has identified significant vulnerabilities in the Medicare hospice benefit and found that hospices did not always provide needed services to beneficiaries and sometimes provided poor quality care. Hospice care can provide great comfort to beneficiaries, their families, and other caregivers at the end of a beneficiary's life. To promote compliance and quality of care, the Centers for Medicare & Medicaid Services (CMS) relies on State agencies and accrediting organizations to survey hospices. As part of this process, surveyors review clinical records, visit patients, and cite hospices with deficiencies when they do not meet Medicare requirements. Hospices must be surveyed at least once every 3 years. Surveyors also investigate complaints. This report provides a first-time look at hospice deficiencies nation-wide in that it includes both hospices that were surveyed by State agencies and those surveyed by accrediting organizations. This report is the first in a two-part series. The companion report addresses beneficiary harm in depth.

The VA Office of the Inspector General (OIG) conducted this audit to follow up on previous reviews of its capital asset programs, which have identified areas of improvement for both major and minor construction projects, and to determine whether VA effectively managed the procurement and awarding of major medical leases under the Veterans Access, Choice, and Accountability Act of 2014 (VACAA). The OIG found that VA major medical leases authorized by VACAA are approximately 22 months behind schedule on average. The management structure of the lease acquisition process spans multiple lines of authority and requires many decisions to execute a lease contract. As a result, lease acquisitions are often slowed when project managers are confronted with conflicting opinions from different management groups. VA has taken some steps to improve the major lease acquisition process, including simplifying the solicitation documentation to better align with General Services Administration practices and changing VA’s mission-critical building standards for leases to better align with similar private sector facilities. However, several of the recommendations remain unaddressed. The OIG recommended VA ensure there are adequate funds available to routinely conduct planning activities including developing requests for lease proposals while waiting for congressional authorization; reconsider centralizing major medical lease acquisition funding activities, make certain adequate resources are available to deliver leases on schedule; ensure that the prospectus cost estimates provided to Congress are accurate; establish clear lines of authority for critical lease acquisition decisions; and adhere to appropriate security measure requirements by performing Interagency Security Committee risk evaluations prior to solicitation. Implementing these recommendations should result in faster and more cost-efficient acquisition of major medical leases.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations related to the discharge of a patient from an inpatient mental health unit at a Veterans Integrated Service Network 4 Medical Facility. The patient was arrested by VA Police, discharged to a federal detention center (FDC), and died eight days later. The OIG identified concerns related to discharge planning processes, voluntary and involuntary admission, use of guidance regarding the patient’s legal and psychiatric status, and patient record flag management. The OIG did not substantiate that the patient died by suicide in the FDC. The Associate Medical Examiner identified the cause of death as hypertensive and atherosclerotic cardiovascular disease and the manner of death as natural. The OIG substantiated that facility staff failed to engage in proper treatment and discharge planning processes. Specifically, staff failed to: • Include the patient and family in treatment and discharge planning, • Address the patient’s decision-making capacity, • Identify and consistently document the patient’s surrogate, • Provide clinical hand-off communication to the receiving mental health providers, despite the patient’s medical and psychiatric acuity and complex medication regimen, • Assign a mental health treatment coordinator, • Obtain a release of information for the VA Police to obtain discharge information, • Obtain consent for voluntary admissions from the surrogate for patients who lack decision-making capacity, and • Consider accessing expert consultative resources to prepare more effectively for patient treatment and discharge. The OIG made 10 recommendations related to inclusion of family in inpatient mental health treatment and discharge planning; assessment of decision-making capacity and voluntary admission status; documentation of a patient’s surrogate; provision of a complete diagnostic summary to receiving providers; assignment of a mental health treatment coordinator; release of information processes; inpatient mental health unit voluntary and involuntary admission processes; and access to consultative resources.

During the week of June 10, 2019, we visited five Border Patrol stations and two ports of entry in the Rio Grande Valley sector and observed serious overcrowding and prolonged detention of children and adults that require immediate attention. Specifically, Border Patrol facilities in the Rio Grande Valley do not have the capacity to hold the thousands currently in custody, and have been holding hundreds of children in custody beyond the 72 hours generally permitted under the TEDS standards and the Flores Agreement.