Federal Reports

The OIG conducted a healthcare inspection in response to allegations regarding Sterile Processing Services (SPS) at the New Mexico VA Health Care System. The OIG team did not substantiate tampering with equipment was occurring or that sterile sets were incorrectly stored or damaged. Thirty-eight of 356 sterile sets inspected were missing instruments; those sets were not consistently labeled as to which instruments were missing. Not all patient safety events were reported as required. Additionally, some surgical procedures were delayed or canceled due to unavailable sterile instruments and equipment. The OIG team determined that, while no patient experienced an adverse clinical outcome related to delays or cancellations, three patients were exposed to increased risks for adverse clinical outcomes. The contract for SPS technicians responsible for reusable medical equipment (RME) reprocessing lapsed in spring 2017. An increase in the number of surgical delays and cancellations occurred for the two months after the contract ended, but the OIG could not establish the surgical delays were related to SPS staffing. Deficiencies in the documentation of SPS staff training and competency records as well as in the maintenance of a comprehensive list of RME and standard operating procedures for some items were identified. The OIG determined the VISN did not provide effective oversight and the facility did not effectively implement proposed action plans, as evidenced by recurring findings reported in multiple inspections. The OIG made 12 recommendations related to missing instruments, verification of items in sterile sets, accurate patient safety event reporting, SPS training, maintenance of an accurate RME list, standard operating procedures, competencies, a review of the SPS contract, implementation of actions from previous reviews and this review, evaluation of the SPS risk assessment, and independent verification by VISN staff, if necessary, to implementation of action plans related to SPS recommendations.

The VA Office of Inspector General (OIG) audited the Veterans Health Administration’s (VHA’s) Emergency Cache Program to determine whether it is maintained in a mission-ready status. VA established the program in 2002 following the 9/11 attacks to ensure drugs and medical supplies are available following a local mass casualty event. Valued at $44 million, VA maintains emergency caches at 141 VA medical facilities around the country. The audit team surveyed the managers of all emergency caches and conducted unannounced inspections at 26 randomly selected emergency cache locations in February 2018. The audit team found expired, missing, or excess drugs, or a combination of, at all 141 emergency caches. There were no required wall-to-wall inventories, and cache managers were not aware of the extent inventories were affected by expired, missing, or excess drugs. As a result of ineffective management, the mission ready status of the caches was impaired. The OIG recommended that VHA establish policies and implement procedures to improve the oversight and management of the program, including developing requirements that all emergency caches perform annual wall-to-wall inventories and improving cache inventory management processes. The OIG also recommended VHA update directives specifying oversight responsibilities, assess whether the program is properly aligned within VA, and coordinate with other VA offices to determine appropriate roles and responsibilities. Finally, the OIG recommended that VHA conduct a comprehensive assessment of the caches’ inventories to identify drugs and supplies that can be used in medical facilities’ general operations and develop a mechanism to ensure medical facilities are maximizing the use of the items before they expire.

After consulting with the Department of the Treasury's Departmental Offices, this report was determined to be releasable pursuant to the Freedom of Information Act.

The objective of this review was to perform an independent assessment of the Peace Corps’ information security program, including testing the effectiveness of security controls for a subset of systems as required, for FY 2018. Our results demonstrate that the Peace Corps lacks an effective information security program. We found problems relating to people, processes, and technology. Furthermore, OIG found weaknesses across all the FISMA reportable areas. To ensure the agency’s information, operations, and assets are protected, it is critical that the Peace Corps achieve full compliance with FISMA and other Federal laws and regulations that apply to managing its IT security infrastructure.

This evaluation focused on the appropriateness of programming, training, and evaluation; the adequacy of Volunteer support; and the effectiveness of post leadership and management. This report contains 24 recommendations, which, if implemented, should strengthen post operations and correct the deficiencies detailed in the report.