Federal Reports

The OIG investigated allegations that a Bureau of Safety and Environmental Enforcement (BSEE) official might have improperly communicated with contractors. The complaint also alleged that the official may have improperly influenced modifications to contracts, and that he might have arranged for an organization to receive a subcontract.We found that the official met with contractors, but that the discussions in these meetings focused only on operations related to the offshore oil and gas industry. We did not find any laws or policies that prohibit these types of meetings. In addition, we found no evidence that the official discussed contracts with the organizations involved or that he influenced the award of any contract modifications or subcontracts.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a complaint that staff at the VA Boston Healthcare System in Massachusetts inappropriately discontinued consults (healthcare providers use consults to request an opinion, advice, or expertise regarding patients’ specific problems). The OIG reviewed a sample of discontinued consults and determined that none of these consults were processed inappropriately. The OIG verified that facility leaders and managers monitored and analyzed consult data, communicated with service leaders about identified concerns, implemented clinical and administrative processes for performance improvement, and monitored the results. The Veterans Integrated Service Network (VISN) provided oversight for tracking patients’ access to care, managing consults, and other facility performance measures. VISN leaders conducted monthly management meetings to review patients’ access to care and consult processing concerns, as well as performance data with facility leaders. Facility managers provided monthly reports on access to care and consult processing to a VISN manager, who tracked facility action plans related to access to care. Based on interviews and review of facility committee minutes and action plans, the OIG concluded that facility leaders were actively engaged and had effective performance improvement and consult management processes in place. Therefore, the OIG made no recommendations.

The VA Office of Inspector General (OIG) reviewed a complainant’s allegations and substantiated that the facility’s providers, at the time of a patient’s most recent hospital admission, failed to complete thorough evaluations including reconciliation of medications. The incomplete evaluation may have contributed to the patient’s declining health and likely hindered the provision of additional needed treatment. Providers failed to appropriately treat the patient’s underlying condition or recognize potential signs of illness such as an elevated white blood cell count. The OIG would have expected the providers to identify and remove the source of infection. The OIG was unable to determine whether the providers’ failures contributed to the patient’s death. The OIG was unable to determine whether system providers discharged the patient without a discussion with the family of the patient’s medical condition. However, the patient was competent and was included in care discussions; including family members in the discussions was not required. The OIG substantiated that providers did not communicate care options to mitigate the patient’s suffering. In addition, podiatry clinic staff did not consistently follow system policy for scheduling appointments and wound care clinic consults were not performed as required. Coordination of care expected for a geriatric patient with chronic illnesses, multiple wounds, and who was “at risk” for foot ulcers was lacking and care was fragmented. Deficiencies in the patient’s care coordination likely contributed to the patient’s worsening wounds. The podiatry attending physician did not document resident supervision in accordance with system policy. The OIG made eight recommendations related to medication reconciliation, provider education, infection source, care transitions, discharge planning, podiatry clinic scheduling, wound care clinic consults and practices, and resident supervision.

The U.S. Department of Housing and Urban Development (HUD), Office of Inspector General audited the Federal Housing Administration (FHA) based on the results of another audit, which found that the lender improperly filed for partial claims before completing the loan modifications and reinstating the loans. Our audit objective was to determine whether FHA improperly paid partial claims that did not reinstate the delinquent loans.We found that FHA improperly paid partial claims that did not reinstate their related delinquent loans. From a sample of 87 partial claims reviewed, FHA paid 47 partial claims totaling more than $2.7 million that did not cure the loan delinquency. By using a statistical projection, we estimated that the FHA insurance fund was unnecessarily depleted by $27.1 million in partial claims. We recommend that the Deputy Assistant Secretary for Single Family Housing (1) take corrective action against lenders for the improper partial claims that did not reinstate the delinquent loans and have not been repaid, (2) design controls to protect the insurance fund from improper partial claims that did not reinstate the loans to put $27.1 million to better use, and (3) update program guidance, clarifying that upon application of the partial claim funds, the mortgage must be fully reinstated with no unpaid amounts.

This report provides the results of our review of the circumstances surrounding the death of Peace Corps Volunteer Bernice Heiderman on January 9, 2018, in Comoros. Our review identified several vulnerabilities associated with the Peace Corps’ failure to provide an early diagnosis and prompt treatment for PCV Heiderman’s malaria. This report makes 7 recommendations to the Peace Corps to address the vulnerabilities we identified and make it more likely that medical officers will provide timely diagnosis and prompt, effective treatment for malaria so that future Volunteer deaths from the disease can be prevented.