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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 Grand Junction Veterans Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 104 employees.The facility has opportunities to maintain the stability of executive leadership with the appointment of a new facility director. OIG noted that current leaders have active engagement with employees and patients and the Daily Management System has improved the effectiveness and speed of communication. 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 and had taken actions to improve performance likely contributing to the current 4-star rating.OIG noted findings in four areas of clinical operations reviewed and issued nine recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Physician utilization management advisors’ documentation of decisions • Feedback about root cause analysis actions (2) Medication Management: Anticoagulation Therapy• Process for addressing anticoagulation-related calls outside of business hours• Quality assurance data reviews(3) Coordination of Care: Inter-Facility Transfers• Inter-facility transfer data reporting• Informed consent and communication of pertinent information to receiving facilities(4) Environment of Care• Attendance of Environment of Care rounds• Locked Mental Health Unit employee and interdisciplinary safety inspection team training

We determined that that U.S. Customs and Border Protection (CBP) was caught by surprise when the President issued the Executive Order (EO) on January 27, 2017. DHS had little opportunity to prepare for and respond to basic questions about which categories of travelers were affected by the EO. We found that the bulk of travelers affected by the EO who arrived in the United States, particularly Lawful Permanent Residents (LPR), received national interest waivers. In addition, we observed that the lack of a public or congressional relations strategy significantly hampered CBP and harmed its public image. While the media reported instances of misconduct, we did not substantiate any claims of misconduct on the part of CBP Officers at the ports of entry. Regarding the Department’s compliance with multiple federal court orders that were issued between the January 27, 2017 release of the EO and the February 3, 2017 nation-wide injunction in Washington v. Trump, we found that at the ports of entry, CBP largely complied with court orders, albeit with some delay and confusion as to the scope of some orders. But while CBP complied with court orders at U.S. ports of entry as to travelers who had already arrived, CBP was aggressive in preventing affected travelers from boarding aircraft bound for the United States. We believe those actions violated two separate court orders that enjoined CBP from this activity.

On January 18, 2018, a former Amtrak Customer Service Representative in Indianapolis, Indiana, pleaded guilty to one misdemeanor count of theft of government funds, in violation of 18 U.S.C. § 641. Our investigation determined that the former employee falsified her application for food stamp benefits while employed by Amtrak. The United States District Court for the Northern District of Illinois ordered her to pay $69,091 in restitution to the U.S. Department of Agriculture and sentenced her to two years of probation.

The Office of Inspector General evaluated NASA’s development of the SWOT mission, a space-based satellite that hopes to produce the first global survey of Earth’s surface water, observe details of the ocean’s surface topography, and measure how water bodies change over time.

OIG conducted a healthcare inspection in response to allegations regarding the Release of Information (ROI) section at the C.W. Bill Young VA Medical Center (facility) of the Bay Pines VA Healthcare System (system), Bay Pines, FL. The complainant alleged that the facility had a backlog of ROI requests, including one pertaining to a patient who died before the non-VHA provider received the records; the Business Office Services (BOS) Chief took ROI requests “off-station” and lost requests; staff working on ROI requests were not trained; and BOS staff did not comply with policies and procedures to process ROI requests.OIG did not identify patient harm attributable to delays in processing the ROI requests. However, OIG found that the facility Patient Advocate Office did not adequately capture ROI complaints. OIG substantiated a ROI request backlog of which system leaders became aware in 2014. OIG also found that ROI staff did not communicate the backlog status to requestors, and that facility managers did not monitor staff productivity accurately. OIG substantiated that the BOS Chief approved transfers of hard copy ROI requests from the facility to an off-site BOS location in an effort to reduce backlog. However, VHA policy authorizes certain managers to remove records from the facility. OIG substantiated that managers were unable to locate 547 ROI requests which were logged into the tracking system from approximately January 2014 through June 2016. Further, OIG found that ROI managers did not fully implement corrections in response to missing authorizations. OIG did not substantiate that staff were not trained to complete assigned ROI tasks. OIG substantiated that ROI staff did not comply with VHA’s prioritization policy and that longstanding workplace culture challenges in the ROI section contributed to the difficulties in resolving the backlog and sustaining effective processes. We made eight recommendations.

Veterans Health Administration’s (VHA) Chief Business Office (CBO) misused approximately $3.1 million of Medical Support and Compliance (MS&C) appropriations when they funded the Debt Management Center’s (DMC) development of the Veterans Health Information Systems and Technology Architecture (VistA) system enhancement. The former Deputy Director, Finance and Logistics for the CBO Revenue Operations, stated she thought she could obligate the MS&C appropriation because it was the only funding available and the DMC recovers costs through its customers. However, public law states that MS&C appropriations are only authorized for necessary expenses in the administration of medical, hospital, nursing home, domiciliary, construction, supply, and research activities—not information technology (IT) development. As a result of our work, in June 2016, the Office of Management reimbursed the VHA the approximately $3.1 million inappropriately used from the MS&C appropriation. We also found that VHA used the MS&C, Medical Services, and IT Systems appropriations to finance five mobile health application development contracts. Public funds may be used only for the purpose for which they were appropriated. However, when an agency has two appropriations available for the same purpose, the agency must select which one to use. The agency must continue to use that appropriation for that purpose unless the agency informs Congress of its intent to change appropriations. VHA’s use of multiple appropriations for the same purpose occurred because it had not updated its financial policies to include how VHA should fund mobile health application development. As a result, VHA lacked consistency and transparency in the execution of its appropriations. We made three recommendations. VA concurred with the recommendations and has taken acceptable corrective actions. The OIG considers the recommendations closed.

To combat money laundering in the U.S., Congress enacted a series of laws, collectively referred to as the Bank Secrecy Act (BSA), requiring financial institutions, including money services businesses (MSB), to deter and detect potential money laundering, and report suspicious activities to the U.S. Department of the Treasury’s Financial Crimes Enforcement Network. Under the BSA, the U.S. Postal Service, defined as a MSB, is required to comply with the law. Our objective was to determine whether the Postal Service anti-money laundering program is adequately designed and implemented to ensure compliance with the BSA and to identify opportunities to enhance the program.