Federal Reports

What We Looked AtThe Department of Transportation's (DOT) mission depends on proper stewardship of funds and effective enforcement of laws and regulations. The Office of Inspector General (OIG) plays a crucial role in supporting DOT's mission by detecting and preventing waste, fraud, abuse, and mismanagement, as well as providing criminal enforcement for violations of law. In order for the Department and our office to fulfill these roles, Operating Administrations must notify us whenever circumstances appear to indicate a potential criminal violation. We initiated this audit to assess DOT's policies and procedures for prompt referral of potential criminal violations to our office.What We FoundDOT's criminal referral policies are not up to date and were unavailable in a central location to DOT employees for almost 2 years. While DOT does not require Operating Administrations to have their own policies or prohibit management involvement, four Operating Administrations have developed policies outlining their internal referral review processes. However, internal processes used by two of the four Operating Administrations may hinder prompt referrals to OIG. Finally, the number of referrals varies across Operating Administrations, and our survey results point to training needs.Our RecommendationsWe made three recommendations to help the Department and its Operating Administrations put policies, procedures, and training in place to enable prompt referral of fraud, waste, abuse, or other potential criminal violations to our office. The Office of the Secretary concurred with two recommendations and partially concurred with one.

What We Looked AtWe reviewed the Utah Transit Authority's single audit report for the fiscal year ending December 31, 2017, to identify findings that affect directly awarded Department of Transportation programs. An independent auditor prepared the single audit report, dated May 29, 2018.What We FoundWe found that the report contained an equipment and real property management finding that needs prompt action from the Federal Transit Administration's (FTA) management.RecommendationsWe recommend that FTA ensures that the Authority complies with the equipment and real property management requirements

What We Looked AtWe reviewed the Metropolitan Council of the Twin Cities' single audit report for the fiscal year ending December 31, 2017, in order to identify findings that affect directly awarded Department of Transportation programs. An independent auditor prepared the single audit report, dated June 18, 2018What We FoundWe found that the report contained a special tests and provisions finding that needs prompt action from the Federal Transit Administration's (FTA) management.RecommendationsWe recommend that FTA ensures that the Council complies with the special tests and provisions requirements.

What We Looked AtWe reviewed the Government of Guam'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 management finding that needs prompt action from the Federal Highway Administration's (FHWA) management.RecommendationsWe recommend that FHWA ensures that the Government of Guam complies with the equipment and real property management requirements.

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 Ralph H. Johnson VA Medical Center (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 25 employees. The Facility has generally stable executive leadership and active engagement with employees and patients as evidenced by satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). 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. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to maintain Quality of Care and Efficiency metrics likely contributing to the “5-Star” rating. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued four recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: (1) Environment of Care • Participation in environment of care rounds • Cleanliness of floors in patient care areas • Maintenance of patient care equipment in clinical areas (2) Women’s Health: Mammography Results and Follow-Up • Scanning of mammogram reports

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 John J. Pershing VA Medical Center (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; and Women’s Health: Mammography Results and Follow-Up. The Facility has a relatively new leadership team, and the Chief of Staff position was vacant at the time of the OIG review. Despite this, the OIG noted that the Facility leaders were actively engaged with employees and patients and had implemented proactive programs to improve satisfaction scores. Organizational leaders supported 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 leadership team was knowledgeable about selected SAIL metrics within their scope of responsibility and should continue to take actions to sustain and improve performance of Quality of Care and Efficiency metrics contributing to the current “4-Star” rating. The OIG noted findings in one of the seven areas of clinical operations reviewed and issued two recommendations that are attributable to the Associate Director. The identified area with deficiencies is: Environment of Care • General cleanliness • Emergency power supply system inspection

The Office of the Inspector General reviewed TVA’s three operating system baselines and how they are applied to the tools used to deploy and manage TVA systems. In summary, we found TVA management aligned two of the three server operating system baselines with the identified best practices and had documentation to support any deviations. However, we found one of the three operating system baselines did not fully align with the identified best practices and was not completely applied to the tools used to deploy and manage TVA server configurations. TVA management agreed with the audit findings and recommendation.