Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Senators Jon Tester and Sherrod Brown to review the care of a patient who fell to his death from a second-story window at the Chillicothe VA Medical Center (Facility), Ohio. At the request of Senator Brown, the OIG also assessed whether the Facility provided grief counseling. The OIG substantiated adequate security and safety measures were not in place and confirmed external windows on the inpatient medicine unit were not secured shut or limited in width of opening as required by Veterans Health Administration policy. The OIG did not substantiate the patient failed to receive an appropriate level of care. The patient had medical and mental health conditions and was managed by both medical and mental health providers on a medical unit. The patient was under special observation status (the patient was to be within the special observer’s eye sight at all times). The special observer was unable to keep the patient under visual observation when the patient entered the bathroom, locked the door, and climbed out the window. The OIG determined that Facility leaders failed to ensure that staff who worked on the unit received required training and competency checks to maintain adherence to Facility policies. The Facility offered grief counseling to the patient’s available family and staff. The OIG found Facility’s attempt to provide an institutional disclosure was inadequate as the Facility did not disclose all significant facts to a family member and did not attempt to locate the patient’s adult child. The OIG made four recommendations related to securing windows in all patient care areas, monitoring compliance with the Special Observation policy and mental health staff training requirements, and conferring with the Office of Chief Counsel concerning family notification of the patient’s death.

The VA Office of Inspector General (OIG) reviewed the Wilmington Health Care Center (HCC) in North Carolina in response to a request from Congressman Walter B. Jones, who asked the OIG to determine whether selecting the Wilmington airport site for the HCC was in the best interest of taxpayers. He also asked the OIG to review the offers to develop the Wilmington HCC to determine whether VA officials used appropriate procedures. The OIG determined the selection of the Wilmington airport site was not in the taxpayers' best interest. VA’s Office of Construction and Facilities Management (CFM) changed its requirements, paid more than the appraised value, and used a flawed two-step process. As a result, VA will pay $2.35 million more than fair market rent over the 20-year lease. This occurred because CFM leadership lacked effective oversight of the lease. CFM has since implemented several policies and procedures negating the need for the OIG to make recommendations on some conditions reported. Specifically, CFM established a policy office and made progress in issuing formal policies and procedures; finalized its handbook, which includes oversight procedures for CFM’s leasing processes; issued official policy and procedures related to the two-step process; and implemented policies and procedures for maintaining lease documentation and transferring that documentation between CFM personnel. The OIG did recommend that the Executive Director for CFM establish a formal policy for transferring contract files when transferring responsibilities to a different contracting officer. Because CFM was unable to provide information to the OIG on all the offers for the development of Wilmington HCC, the OIG was unable to determine whether CFM used appropriate procedures during the selection and award process of the $69 million lease.

What We Looked AtIn 2012, the Department of Transportation (DOT) implemented electronic invoicing (eInvoicing) for grant invoice processing across the Department. While DOT developed standardized eInvoicing training at the department level, individual Operating Administrations developed their own eInvoicing guidance and processes for grantees submitting payment requests. We assessed the Federal Aviation Administration's (FAA) policies, procedures, and oversight for eInvoicing in the Airport Improvement Program (AIP). The AIP is one of DOT's largest grant programs, providing approximately $3 billion a year to sponsors (grantees) including commercial and general aviation airports to support projects that improve safety and efficiency. We tested AIP payments to grantees to determine if they met FAA's eInvoicing requirements. Our objectives were to (1) evaluate FAA's implementation of eInvoicing in AIP and (2) assess whether AIP grant payments were supported and valid.What We FoundThe guidance and internal control procedures FAA developed for eInvoicing were not always followed. FAA developed a risk-based approach to oversight of AIP grantees and their payments, yet FAA staff responsible for oversight did not always adhere to the control procedures. Additionally, AIP grantees requested and were paid millions of dollars without complying with FAA's eInvoicing documentation requirements to support payment requests. Using statistical sampling, we estimate that about $751 million (12.5 percent) of the $6 billion in AIP payments during fiscal years 2015 and 2016 were non-compliant with FAA eInvoicing supporting documentation requirements. Finally, we found that AIP grant payments were not always fully supported and valid. We identified questioned costs totaling about $1 million because grantees did not always maintain complete and valid support, funds were paid in excess of the allowable Federal share, and a grant agreement was not amended when applicable.Our RecommendationsOf our eight recommendations to improve implementation of eInvoicing and communicate policies to grantees and FAA Regional and Airport District Office staff, FAA concurred with seven and partially concurred with one.

What We Looked AtThis report presents the results of a quality control review (QCR) of an audit of the Department of Transportation's (DOT) Enterprise Services Center (ESC) controls. ESC provides financial management services to DOT and other agencies, and operates under the direction of DOT's Chief Financial Officer. The Office of Management and Budget (OMB) requires ESC, as a management services provider, to either provide its user organizations with independent audit reports on the design and effectiveness of its internal controls, or allow user auditors to perform tests of its controls.We contracted with KPMG LLP to conduct this audit subject to our oversight. The objectives of the review were to determine whether (1) management's descriptions of ESC's systems are fairly presented, (2) ESC's controls are suitably designed, and (3) ESC's controls are operating effectively throughout the period of October 1, 2017 through June 30, 2018. We performed a QCR on KPMG's report and related documentation.What We FoundOur QCR disclosed no instances in which KPMG did not comply, in all material respects, with generally accepted Government auditing standards.RecommendationsDOT concurs with KPMG's 11 recommendations.The quality control review and attachments have been marked as For Official Use Only to protect sensitive information exempt from public disclosure under the Freedom of Information Act, 5 U.S.C. § 552. To receive a copy of the report, please contact our Freedom of Information Act Office.

What We Looked AtWe reviewed the Navajo Nation's single audit report for the fiscal year ending September 30, 2017, in order to identify findings that affect directly awarded Department of Transportation programs. An independent auditor prepared the single audit report, dated June 25, 2018.What We FoundWe found that the report contained an equipment and real property finding that needs prompt action from the Federal Highway Administration's (FHWA) management.RecommendationsWe recommend that FHWA ensures that the Navajo Nation complies with the equipment and real property requirements.

What We Looked AtWe reviewed the Republic of Palau's single audit report for the fiscal year ending September 30, 2017, in order to identify findings that affect directly awarded Department of Transportation programs. An independent auditor prepared the single audit report, dated July 31, 2018.What We FoundWe found that the report contained an equipment and real property management finding that needs prompt action from the Federal Aviation Administration's (FAA) management.RecommendationsWe recommend that FAA ensures that the Republic complies with the equipment and real property management requirements.

What We Looked AtWe reviewed the Middletown Transit District's single audit report for the fiscal year ending June 30, 2017, in order to identify findings that affect directly awarded Department of Transportation programs. An independent auditor prepared the single audit report, dated July 10, 2018.What We FoundWe found that the report contained a procurement and suspension and debarment finding that needs prompt action from the Federal Transit Administration's (FTA) management.RecommendationsWe recommend that FTA ensures that the District complies with the procurement and suspension and debarment requirements.

OIG reviewed APHIS’, ARS’, and FSIS’ plans and actions to prevent, detect, andrespond to agroterrorism threats or attacks.