Federal Reports

The OIG investigated allegations that a Bureau of Land Management (BLM) employee violated conflict of interest laws by steering BLM contracts to a business that he owned.The employee admitted to the conflict of interest and that his actions were wrong. We found that the employee’s wife owned a business and that between April 2016 and August 2017, the employee steered 11 contracts, totaling $27,409.60, to his wife’s business. We also learned that in December 2017, the employee submitted an altered purchase approval form to facilitate payment to his wife’s business, but the BLM did not pay that claim. We did not find that the business failed to provide any of the services for which it was paid.Finally, we determined that the employee failed to list his wife’s business as a source of reportable income for his wife on his annual Confidential Financial Disclosure Reports that he filed with the BLM in 2016, 2017, and 2018. The employee agreed that he should have disclosed the information but denied that he intentionally omitted it as an effort to conceal that his wife owned the business.The U.S. Attorney’s Office for the District of Montana declined prosecution. This is a summary of a report we provided to the BLM Director.

The Federal Labor Relations Authority (FLRA) OIG reviewed the system of quality control for the audit organization of the Federal Trade Commission (FTC) OIG in effect for the period ended March 31, 2018. The FTC OIG received an External Peer Review rating of PASS. In the FLRA OIG's opinion, the system of quality control for the audit organization of the FTC OIG in effect for the period ended March 31, 2018, had been suitably designed and complied with to provide the FTC OIG with reasonable assurance of performing and reporting in conformity with applicable professional standards in all material respects.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review circumstances surrounding a Residential Rehabilitation Treatment Program patient’s death from heroin overdose at a Veterans Integrated Service Network (VISN) 1 medical facility (facility). The OIG determined that protocols were not in place for initiating patients’ medication-assisted therapy. At the time of the patient’s death, a specific protocol was not in place to start patients on Suboxone®, a medication that assists with reducing opioid withdrawal symptoms. Five facility providers said they did not know or could not articulate the process for a patient to obtain Suboxone® therapy. Additionally, a formal Standard Operating Procedure or policy regarding tracking patient no-shows to an off-site substance abuse day program was not in place. The OIG also found Veterans Health Administration’s (VHA) urine drug testing policy was not followed when staff failed to collect the patient’s urine specimen. The facility amended its urine drug testing practice after this patient’s death. An emergency response team was called when the patient was found unresponsive, but resuscitation attempts were not initiated due to medical futility. The Cardiopulmonary Resuscitation Committee did not initially review documentation related to the patient’s death because treatment was not initiated. According to VHA policy, facilities are only required to review events where resuscitation was attempted. While the facility had process deficiencies, the OIG could not determine how or to what extent the deficiencies contributed to or had impact on the patient’s death. The OIG made three recommendations related to medication-assisted therapy initiation, no-show policies, and staff training on no-show procedures.

The U.S. Department of Health and Human Services (HHS), Administration for Children and Families (ACF), did not always resolve audit recommendations in a timely manner during Federal fiscal years (FYs) 2015 and 2016. Specifically, ACF resolved 1,570 of the 2,248 audit recommendations that were outstanding during FYs 2015 and 2016. However, it did not resolve 1,392 of the 1,570 recommendations (88.7 percent) within the required 6-month resolution period. In addition, as of September 30, 2016, ACF had not resolved 678 audit recommendations that were past due for resolution. The dollar amounts associated with these past-due recommendations totaled $36.5 million.