Federal Reports

In a previous audit - the Performance Audit of USCP Controls Over Evidence, Report Number OIG-2015-03, dated March 2015 - the Office of Inspector General (OIG) found that the United States Capitol Police (USCP or the Department) should improve internal controls for ensuring the integrity of physical evidence collected, secured, and processed. As a part of its general oversight responsibility for USCP, OIG conducted a follow-up analysis of the Department's implementation of recommendations contained in Report Number OIG-2015-03. Our objective was to confirm the Department took the corrective actions in implementing the recommendations. Our scope included existing controls over evidence related to the implementation of recommendations as outlined in our previous report.

To watch a short video regarding this report, please click the link below.

The OIG’s data analysis identified Raleigh, NC, Westgate Passport Facility had local purchases totaling $12,725, or 41 percent of all local purchases in the Greensboro District, for the period January 1 through March 31, 2018. It is unusual for one office to have such a high percentage of local purchases as it relates to other offices in the same district. Our objective was to determine whether local purchases and payments were valid and properly supported at the Raleigh, NC, Westgate Passport Facility.

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The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding quality of care issues in two Community Living Centers (CLC) at the Northport VA Medical Center, New York. The OIG substantiated Patient A died at the facility after choking on food, but found insufficient evidence to attribute the cause of the choking to the lack of nurse staffing. The OIG substantiated the facility operator called the wrong code, leading to multiple responders, role confusion, and a delay in transporting Patient A to the Emergency Department. The OIG did not substantiate managers misrepresented the cause of death as cardiac arrest. OIG inspectors found inconsistent emergency medical response policies, post-code debriefings, and medical oversight and determined Patient A’s case warranted additional facility review. The evidence was insufficient for the OIG to substantiate or not substantiate whether patients were regularly left unsupervised while eating. The OIG did not substantiate one CLC lacked security due to malfunctioning door locks. The OIG substantiated a lack of consistent documentation of rounds but was unable to ascertain if this condition reflected an absence of completed rounds and decreased unit security. The OIG was unable to substantiate or not substantiate a lack of staff vigilance. The OIG substantiated Patient B’s wrists were bound together by a palm protector strap but did not find evidence to suggest an intentional act done by staff due to a lack of available nursing staff. The OIG did not substantiate that CLC nursing managers were often unavailable and failed to provide adequate response to unit issues. The OIG made eight recommendations to the Facility Director and one recommendation to the Veterans Integrated Service Network Director related to emergency medical response processes and policies, CLC meal staffing and delivery processes, safety rounds, and reviews of Patient A’s care.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding inadequate nurse staffing that affected quality of care in the Community Living Centers (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that nursing leaders were aware of staffing shortages in the CLCs, and the OIG confirmed the use of float staff and overtime. However, due to variables that contribute to the delivery of safe patient care, OIG inspectors were not able to substantiate or not substantiate that the use of float staff and overtime placed residents at a higher risk for adverse events. The OIG found the Facility failed to consider or utilize alterative staffing. The OIG found a lack of CLC nurse staffing due in part to a delay in filling vacant positions and a lack of approval to increase staff. In addition, OIG inspectors’ review of overtime data indicated that the overtime funding exceeded the cost associated with filling the vacant positions. The OIG substantiated that registered nurses assigned to administrative roles were utilized to provide nursing care in the CLCs. The OIG inspectors found no evidence of deficiencies or indications that the administrative nurses performed work outside of the registered nurse position description. The OIG substantiated that previous Facility leaders pressured CLC managers to accept admissions when nurse staffing was inadequate to provide expected levels of care for additional residents. However, CLC nurse managers reported improvement since August 2017 with the new Facility leadership team. The OIG substantiated that the CLCs were closed to admissions at times. However, OIG inspectors did not substantiate that residents were transferred to acute care inpatient units due to lack of CLC staffing. The OIG made three recommendations related to CLC nurse staffing and recruitment, alternative staffing, and overtime management.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding a patient’s abuse and neglect in a community living center (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that a patient who died at the facility fell while living in a facility CLC and required surgery for a hip fracture sustained during the fall. The OIG did not substantiate that the patient’s fall was caused by inadequate fall precautions or that the patient’s death was caused by abuse or neglect. The OIG substantiated that the patient did not receive anticoagulation injections to prevent blood clots following surgery for hip fracture per facility protocol. The OIG did not substantiate that the failure to receive three of the four doses of anticoagulation medication during the hospital stay contributed to the patient’s death. The OIG was unable to substantiate or not substantiate that a staff member who performed one-to-one observation of the patient failed to provide proper observation during the shift when the patient died, because the OIG was unable to resolve discrepancies between facility documentation and staff interviews. The OIG did not substantiate that the CLC Nurse Manager received complaints about staff behaviors that negatively impacted patient care and failed to take corrective action. The OIG did not substantiate that facility leaders or managers tried to cover up the circumstances surrounding the patient’s death. However, the OIG determined that the missed anticoagulation medication doses were not addressed in the facility’s quality management review of the patient’s care. The OIG made three recommendations related to reviewing the accuracy of 24-Hour Observation Flow Sheets, conducting an updated quality management review of the patient’s case, and consulting with the Office of General Counsel about missed anticoagulation doses and institutional disclosure to the patient’s family.