Federal Reports

The VA Office of Inspector General (OIG) reviewed Veterans Benefits Administration’s (VBA’s) denied claims related to veterans’ military sexual trauma (MST) to determine whether staff correctly processed the claims according to VBA policy. Some service members are reluctant to submit a report of MST, particularly when the perpetrator is a superior officer. Victims may have concerns about the potential for negative performance reports or punishment for collateral misconduct. There is also sometimes the perception of an unresponsive military chain of command. If the MST leads to posttraumatic stress disorder, it is often difficult for victims to produce evidence to support the occurrence of the assault. VBA policy, therefore, requires staff to follow additional steps for processing MST-related claims so veterans have additional opportunities to provide adequate evidence. Based on its sample, the OIG estimated that VBA staff incorrectly processed about 1,300 of the 2,700 MST-related claims denied during the review period April 2017 through September 2017. This may have resulted in the denial of benefits to veterans who could have been entitled to receive them. The OIG determined multiple factors led to the improper processing and denial of MST-related claims, including lack of reviewers’ specialization and no additional level of review, discontinued special focus reviews, and inadequate training. The OIG made six recommendations to the Under Secretary for Benefits including that VBA review all approximately 5,500 MST-related claims denied from October 2016 through September 2017, take corrective action on those claims in which VBA staff did not follow all required steps, assign MST-related claims to a specialized group of claims processors, and improve oversight and training on addressing MST-related claims.

The agreed-upon procedures (AUP) review of AmeriCorps grant funds to SerVermont, Vermont’s State Service Commission and two subrecipients identified questioned Federal costs totaling $122,551, questioned matching costs of $38,746, questioned Education Awards of $40,342 and compliance findings. The majority of the questioned costs were caused by deficiencies with National Service Criminal History Checks. The costs tested were incurred between April 15, 2015 and August 31, 2017.SerVermont concurred that the auditors found noncompliant NSCHCs at the Commission and the two subrecipients but disagreed on the related questioned costs. The Corporation will resolve the report’s findings and recommendations.

At the request of the Tennessee Valley Authority's (TVA) Supply Chain, we examined the labor and labor markup rates included in a contract TVA has with a contractor. Our examination objective was to determine if the contract's labor and labor markup rates were fairly stated for a planned 5-year contract extension.In our opinion, the contract's labor and labor markup rates were fairly stated. Specifically, the contract's labor markup rates were supported by the contractor's actual historical costs, and the contractor's proposal to update the contract's wage ranges was reasonable. (Summary Only)

We examined the customer experiences associated with the Postal Service’s Customer Care Centers (CCCs). We found four ways USPS could improve the customer experience: preventing calls with better information and fixing underlying issues; decreasing customer effort when calling the CCCs; shortening the wait to speak to an agent; and improving the ability of agents to solve problems on the spot. We also identified a business arrangement that could affect the overall customer experience.

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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 Erie 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 OIG also provided crime awareness briefings to 74 employees. The Facility has stable executive leadership and active engagement with employees and patients as evidenced by high 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, and Patient Safety Indicator data did not identify any substantial organizational risk factors. Although the leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics and the Facility is currently rated as “5-Star,” the leaders should continue to take actions to improve or maintain performance of Quality of Care metrics. The OIG noted findings in three of the seven areas of clinical operations reviewed and issued three recommendations that are attributable to the Chief of Staff and Associate Director for Patient Care Services. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Protected peer review process (2) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (3) Environment of Care • Medication administration, storage, and disposal processes