Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Central Texas Veterans Health Care System. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-risk Processes: Central Line-associated Bloodstream Infections. The Facility had relatively stable executive leadership and active engagement with employees as evidenced by satisfaction scores. However, opportunities exist to improve outpatient experiences. Additionally, the OIG identified the presence of organizational risk factors with Patient Safety Indicator data and delays in patients receiving sleep apnea equipment, which may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The OIG noted findings in five of the clinical operations reviewed and issued 18 recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, Associate Director, Assistant Director–Austin, and Assistant Director–Waco. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Personal protective equipment accessibility • Environmental cleanliness • Medical equipment availability • Panic alarm testing and follow-up • Annual Emergency Operations Plan reviews (3) Medication Management: CS Inspection Program • Monthly and quarterly reports • CS inspectors’ appointments • Monthly area inspections • Verification of drugs held for destruction and hard copy prescriptions • Prescription pad accountability (4) Women’s Health: Mammography Results and Follow-up • Communication of results to patients (5) High-risk Processes: Central Line-associated Bloodstream Infections • Staff education

During the financial statement audit, OIG’s contracted independent public accountant, CliftonLarsonAllen LLP, assessed PBGC’s information security infrastructure for technical weaknesses in PBGC’s computer systems that may allow employees or outsiders to cause harm to, and/or impact, PBGC’s business processes and information. Current year testing found weaknesses in the areas of configuration management, data protection and privacy, and identity and access management. This report includes three new recommendations and five repeat recommendations. The Office of Inspector General has determined that this report is for official use only. The report detailing the vulnerability assessment has been redacted in its entirety because it contains privileged and confidential information.

This is a report of FHFA-OIG’s administrative inquiry into allegations of misconduct by the FHFA Director. The size of the report with exhibits included exceeds the maximum file size that can be posted on Oversight.gov. The full report with exhibits is available on OIG’s website in the Status and Special Reports section, https://www.fhfaoig.gov/reports/StatusReports, or by clicking the "Additional Details Link" below.

Management and Performance Challenges Facing the Railroad Retirement Board

The Tennessee Emergency Management Agency (Tennessee) did not ensure Nashville-Davidson County, Tennessee (County) always accounted for and expended grant funds according to Federal regulations and Federal Emergency Management Agency (FEMA) guidelines. The County received a net grant award of $70.3 million for damages resulting from a May 2010 flood. We audited and reviewed 70 projects totaling $26.6 million — 62 percent — of the $43.1 million awarded for permanent work. Because of the complexity of the projects and the dollar amount of the award, we divided the audit into two phases. In this second phase, we focused on project awards totaling $43.1 million the County received for permanent work, except for seven small projects with contract costs totaling $2,271 related to emergency work.

Corporación Salud Asegurada por Nuestra Organización Solidaria, Inc. (SANOS), a Health Resources and Services Administration (HRSA) grantee located in Caguas, Puerto Rico, generally complied with applicable Federal requirements and grant terms related to its Community Health Center Program grants. Specifically, SANOS had adequate financial management controls over supplemental grant funds and followed Federal procurement standards. However, we determined that SANOS claimed $4,000 in unallowable advertising costs.

The OIG investigated allegations that senior management within the Bureau of Ocean Energy Management (BOEM) Gulf of Mexico Region reprised against an employee for disclosures she made to BOEM officials. The employee also filed similar complaints under Equal Employment Opportunity (EEO) provisions.During our investigation, the U.S. Department of the Interior (DOI) Office of Civil Rights issued a finding that the employee was discriminated against and subjected to reprisal and a hostile work environment by a former BOEM supervisor. The former BOEM supervisor resigned from Federal service before the Office of Civil Rights issued its finding.The employee subsequently settled with the DOI to resolve all claims, some of which pertained to matters under our investigation. Because of the resolution provided under the settlement agreement, we concluded our investigation.