Federal Reports

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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 Bay Pines VA Healthcare System (Facility). 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 Inspection Program; Mental Health Care: Post-Traumatic 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 OIG also provided crime awareness briefings to 164 employees. The Facility is moving towards establishing a stable leadership team with the addition of a new Associate Director and Assistant Director since the OIG’s site visit. The OIG also noted active engagement with employees and patients. Organizational leaders support patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the “3-Star” ranking. The OIG noted findings in four of the clinical operations reviewed and issued four recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) Environment of Care • Cleanliness of patient care areas (2) Medication Management: Controlled Substances Inspection Program • Alternate Controlled Substances Coordinator (CSC) position description (3) Long-Term Care: Geriatric Evaluations • Comprehensive psychosocial assessments (4) High-Risk Processes: Central Line-Associated Bloodstream Infections • Staff education

The OIG investigated allegations that a former Bureau of Reclamation (USBR) manager influenced the award of a $21 million environmental consulting contract to a firm that employed him after he left the USBR. The allegations further stated that a USBR supervisory contract specialist had a conflict of interest with managing the contract process because of her romantic relationship with the USBR manager.We found no evidence that the manager personally or substantially participated in the contract or that he influenced the award while he was employed by the USBR. We also investigated whether the manager violated post-Government employment restrictions with his employment at the firm, whether he used his position to gain employment, or whether he shared sensitive information with the firm. We found no evidence that the manager violated any restrictions, that he used his position to gain employment, or that he shared sensitive information with the firm. We also found no evidence that the supervisory contract specialist had a conflict of interest with managing the contracting staff, or that she should have recused herself from the contract process. The contract was deemed invalid and canceled because the award exceeded the contracting officer’s warrant authority. That decision was unrelated to this investigation.

We reviewed recommendations 1, 2, 3, 4, 5, and 7 presented in our February 9, 2016 report, titled “Inspection of the U.S. Department of the Interior’s Occupational Safety and Health and Workers’ Compensation Programs,” to verify that the U.S. Department of the Interior (DOI) has implemented them. We confirmed that the DOI met the requirements of Recommendations 1, 2, 4, and 5. We consider these four recommendations resolved, implemented, and closed. Recommendations 3 and 7 have not been implemented, however, since the DOI plans to take no additional action to implement the recommendations, we consider them closed.

We audited the costs claimed by the Arizona Game and Fish Department (Department), under grants awarded by the U.S. Fish and Wildlife Service (FWS). The FWS provided the grants to the State under the Wildlife and Sport Fish Restoration Program. The audit included claims totaling $70.2 million on 11 grants that were open during the State fiscal years that ended June 30, 2014, and June 30, 2015. The audit also covered the Department’s compliance with applicable laws, regulations, and FWS guidelines, including those related to collecting and using hunting and fishing license revenue and reporting program income.We questioned costs totaling $3,948,965 due to 1) unallowable payroll charges, 2) out-of-period costs, 3) inadequate subrecipient financial management systems, 4) deficiencies in documenting in-kind contributions, and 5) inadequate competition. In addition, we determined that the Department:Potentially diverted license revenue by writing off $21,276 from the State’s accounting records without maintaining adequate documentation to justify this actionDid not consistently comply with subaward requirementsSubmitted annual performance reports to the FWS that were missing key informationDid not comply with all comprehensive management system requirementsInappropriately drew down $23,425 in Federal funds from the FWSThe FWS Region 2 and the Department responded to our draft report. We consider all recommendations to be resolved but not implemented

We audited costs claimed by the State of Louisiana, Department of Wildlife and Fisheries (Department), for grants awarded by the U.S. Fish and Wildlife Service (FWS) under the Wildlife and Sport Fish Restoration Program. We audited claims totaling $69.2 million on 52 grants that were open during the State fiscal years that ended June 30, 2015, and June 30, 2016. Our audit also covered the Department’s compliance with applicable laws, regulations, and FWS guidelines, including those related to collecting and using hunting and fishing license revenue, and reporting program income.We questioned costs totaling $148,000 ($111,000 Federal share) as out-of-period costs. We also determined that the Department had not properly classified its subawards and had not requested prior written approvals for large monetary purchases or multiple purchases of the same item. We also found inadequate support for its claimed in-kind contributions and equipment funding source from its equipment database system.The Department and the FWS provided responses to our draft report. Based on these responses, we consider all eight recommendations resolved but not implemented.