Federal Reports

The objective of the Council of the Inspectors General on Integrity and Efficiency purchase card initiative was to analyze and review Government purchase card data to determine the risks associated with purchase card transactions.

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 VA San Diego 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 63 employees. The Facility has stable executive leadership. The OIG noted generally satisfied employees; however, opportunities exist to improve inpatient experiences. Organizational leaders supported patient safety, quality of 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 results did not identify any substantial organizational risk factors, but the executive leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the “3-Star” rating. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director of Patient Care Services, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Ongoing Professional Practice Evaluations (2) Environment of Care • Environment of care rounds attendance • Environmental cleanliness (3) Medication Management: Controlled Substances Inspection Program • Controlled substances reconciliation (4) High-Risk Processes: Central Line-Associated Bloodstream Infections • Staff education

What We Looked AtThis report presents the results of our quality control review (QCR) on the single audit that Ricci & Company, LLC performed for the Rio Metro Regional Transit District's (District) fiscal year that ended June 30, 2016. During this period, the District expended approximately $14 million from the U.S. Department of Transportation's (DOT) grant programs. Ricci determined that DOT's major program was the Federal Transit Cluster.Our QCR objectives were to determine whether (1) the audit work complied with the Single Audit Act of 1984, as amended, the Office of Management and Budget's Uniform Guidance, and the extent to which we could rely on the auditors' work on DOT's major program; and (2) the District's reporting package complied with the reporting requirements of the Uniform Guidance.What We FoundRicco's audit work complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT's major program. We found nothing to indicate that Ricci's opinion on DOT's major program was inappropriate or unreliable. However, we identified deficiencies in the District's reporting package that required correction and resubmission.

What We Looked AtFederal regulations require U.S. air carriers to verify the airworthiness of aircraft following major repairs or maintenance. To perform these maintenance checks, American Airlines (AA) established a flight test program. In February 2017, the Allied Pilots Association (APA)--which represents AA's pilots--contacted us about multiple safety issues at the AA flight test program, including the use of unqualified pilots. APA stated that concerns placed in an earlier letter to the Federal Aviation Administration (FAA) had remained "largely unaddressed for over 18 months." We initiated an audit to assess the effectiveness of FAA's actions in response to safety concerns about the AA flight test program. Specifically, we examined how (1) FAA's oversight office for American Airlines addressed concerns about the flight test program and (2) the Agency processed and responded to a letter to the Federal Aviation Administrator questioning the integrity of FAA's oversight of the flight test program.What We FoundFAA's oversight office for American Airlines lacked objectivity in its review. While FAA requires inspectors to provide impartial treatment, the inspector in this case seems to have been affected by his relationship with AA personnel and the 28 years he spent working with the carrier. While the Agency has a tool for assessing its relationships with carriers, the tool did not account for these risk factors. In addition, the Agency used a "best guess" method to determine who should respond to APA's written allegations, and ultimately routed the letter back to the target of the complaint for response. Due to a lack of oversight guidance, FAA also provided varying responses to APA and OIG regarding the requirements for the flight test program. As a result, APA received neither a comprehensive nor an accurate response to its concerns.Our RecommendationsFAA concurred with our seven recommendations to improve its oversight of the flight test program, as well as its ability to respond to safety concerns.

The OIG investigated allegations that a United States Geological Survey (USGS) manager made unwelcome and inappropriate comments of a sexual nature to a female subordinate.We found that the USGS manager provided inconsistent statements and demonstrated a lack of candor during interviews, but ultimately admitted to making inappropriate sexual comments to the female subordinate. We also found that the manager had been counseled by a former supervisor in 2013 for allegedly making similar comments to other employees and, consequently, had been required to take Equal Employment Opportunity training; the manager had also been counseled by a current supervisor in 2016 for the same reason.

The OIG investigated an allegation that a tribal official stole Federal funds by using a tribal charge card for personal expenses.We found that the official embezzled more than $98,000 by charging personal expenses to tribal government charge cards assigned to him from December 2009 until July 2015, when the tribe canceled all tribal government charge cards. The theft included charges for restaurants, airfare, retail purchases, food, and utility and telephone services. The charges were billed to the tribe and paid using a combination of Federal and tribal funds.The U.S. Attorney’s Office for the District of Rhode Island declined prosecution. The tribal official refused our request for an interview.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Beckley VA Medical Center (Beckley), West Virginia, regarding a complainant’s allegations that delays in urological care, including kidney surgery, and an increase in a kidney lesion’s size occurred that resulted in an adverse clinical impact to a patient’s urological health. The OIG further evaluated if other Beckley patients experienced delays in urological care that resulted in adverse clinical impacts, and if Beckley lacked funding for its non-VA care programs. The OIG substantiated that the patient experienced delays in urological care, including kidney surgery, and that a kidney lesion increased in size; however, the lesion size was not within the range that necessitated immediate surgery or intervention. OIG staff found that the patient’s care was monitored by providers who discussed the patient’s symptoms with the patient and other providers. The OIG did not find that delays caused an adverse clinical impact to the patient’s urological health. The OIG also identified delays in scheduling urology consults for the Beckley Outpatient Urology Clinic and non-VA care programs. OIG staff determined that none of the reviewed patients experienced an adverse clinical impact to their urological health due to a delay in the consult process. Although a Beckley non-VA care staff member informed the patient that Beckley lacked funding for referral to non-VA care, the staff member made this statement in error, and Beckley leaders addressed and corrected the error. Beckley had sufficient funding, and providers routinely referred patients to other VA and non-VA facilities. The OIG made one recommendation related to reviewing consult management practices and ensuring consult timeliness.