Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations that the Samuel S. Stratton VA Medical Center’s peer review processes did not follow Veterans Health Administration (VHA) policy; the surgeon performed intraoperative radiofrequency ablation (IORFA) surgery for hepatocellular carcinoma and “completely missed” tumors in patients; a surgeon told a patient there was a recurrence of a tumor although it was “completely missed” during IORFA surgery; the surgeon performed cancer surgery on patients who did not have cancer; and adverse events occurred during and after the surgeon’s other cancer surgeries. The OIG substantiated the facility’s peer review process did not follow VHA policy, and the facility did not meet credentialing and privileging requirements. The OIG substantiated the surgeon completely or partially missed tumors when performing IORFA in three patients and told patients they had residual tumors when tumors were not initially ablated. The OIG determined that facility leaders did not provide disclosures for the patients reviewed. The OIG did not substantiate the surgeon performed surgery on patients who did not have cancer or that adverse events occurred during cancer surgeries. The OIG made nine recommendations related to reviewing quality oversight and quality data for professional practice evaluations; improving peer review programs; including accurate performance data for Surgery Service’s professional practice evaluations; developing and implementing processes to document, report, and track discussed patient cases; implementing processes to track, monitor, and report IORFA outcomes; consulting with Office of General Counsel on patients with missed tumors to institutionally disclose if appropriate; assessing the Surgeon’s IORFA outcomes; performing external reviews of IORFA processes; and evaluating actions for relevant staff.

The VA Office of Inspector General (OIG) reviewed whether the Veterans Benefits Administration (VBA) accurately notified veterans of proposed reductions in their disability evaluations and assigned correct effective dates for reduced evaluations completed from February 1 through July 31, 2017. The OIG estimated that 2,200 of 5,900 cases (38 percent) were processed incorrectly by VBA staff, resulting in an average improper payment rate of $2,000 per veteran. The OIG estimated that over a five-year period, VBA staff would make improper payments to over 22,300 veterans totaling more than $27.5 million. In addition, based on the OIG’s projections and estimates, veterans potentially could have received improper payments totaling approximately $10.4 million, of which approximately $7.8 million would be ongoing monthly improper payments. Errors included the assignment of incorrect effective dates for reduced disability evaluations; staff not sending amended notifications when the reasons for the proposed reductions changed; and staff providing inaccurate, or failing to send, initial notifications to veterans that their benefits may be reduced. These errors occurred because VBA staff did not always immediately process final actions for reduced evaluations, VBA’s electronic claims processing system defaulted to incorrect effective dates, compensation service staff did not require refresher training on how to process reduced evaluations, Veteran Service Representatives were more focused on meeting workload production standards and not ensuring correct effective dates, and VBA procedures did not specify when staff need to send notifications in the event a veteran’s disability evaluation is reduced. The OIG recommended VBA implement a plan to ensure the timely processing of these cases; modify the Veterans Benefits Management System to apply correct effective dates; provide refresher training; update guidance on amended proposal letters; and conduct reviews for veterans who had evaluations reduced, take corrective action, and provide certification of completion to the OIG.

A limited scope performance audit (LSPA) of the Texas Commission on the Arts (TCA) was conducted for the period of April 1, 2015 through March 31, 2018. LSPAs involve a limited review of financial and non-financial information of award recipients to ensure validity and accuracy of reported information, and compliance with federal requirements. Our limited scope audit concluded that the TCA generally complied with the financial management system and recordkeeping requirements established by the OMB and NEA. However, we determined that the TCA included costs incurred outside the period of performance on the Federal Financial Report (FFR) for award No. 15-6100-2046. Additionally, the financial management system does not reconcile to the FFRs for award Nos. 15- 6100-2046 and 16-6100-2024; notice of federal award participation was not provided to subaward recipients used to meet the federal cost share/match; reviews were not conducted to ensure that subaward recipients were not suspended or debarred from receiving federal funds; and Section 504 Self-Evaluation was not maintained on file during the audit period.

This grant provided ARC funds and a required matched funds in non-ARC funds to provide support for the Master's Degree/Certification Project which is designed to improve the quality of education in the Eastern Kentucky region

The OIG investigated allegations that a senior official from the Bureau of Land Management (BLM) encouraged natural resource specialists to overlook regulations so they could process Applications for Permit to Drill more quickly, and to protect any staff members who overlooked the regulations Our investigation did not substantiate the allegations and found no evidence to indicate the senior official encouraged staff to overlook the regulations as alleged. We found the senior official did meet with a group of natural resource specialists and encouraged them to streamline processes, but he did not direct staff to overlook regulations.

The OIG investigated allegations that Great Western Drilling Corporation (GWD) misreported mineral royalty data to the Office of Natural Resources Revenue (ONRR) and underpaid Federal mineral royalties.We substantiated the allegations and found that for more than 6 years, the GWD violated Federal regulations and ONRR rules when they deducted their costs incurred transporting and processing natural gas and associated natural gas liquids into marketable condition from its royalty obligations to the ONRR. Because of these violations, the GWD underpaid Federal royalties to the ONRR.The United States Attorney’s Office for the District of Colorado entered into a civil settlement agreement with the GWD for $600,000 to resolve this case.