Federal Reports

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The VA Office of Inspector General (OIG) conducted a risk assessment of the three types of charge cards used by VA—purchase cards (including convenience checks), travel cards, and fleet cards. Office of Management and Budget Memorandum M-13-21, Implementation of the Government Charge Card Abuse Prevention Act of 2012, requires Inspectors General to conduct annual risk assessments of illegal, improper, or erroneous purchases within charge card programs. Based on its risk assessment of VA’s fiscal year (FY) 2017 charge card transactions, the OIG determined that VA’s Purchase Card Program remains at medium risk of illegal, improper, or erroneous purchases. The data mining of purchase card transactions identified potential misuse of purchase cards, and OIG investigations, audits, and reviews continue to identify patterns of purchase card transactions that do not comply with the Federal Acquisition Regulation and VA policies and procedures. The VA Purchase Card Program is the largest VA charge card program, as measured by both the number of transactions and the amount of spending. Agency purchase card spending increased from about $4.1 billion in FY 2016 to about $4.2 billion in FY 2017. The OIG determined that VA’s Travel and Fleet Card Programs have a low risk level of illegal, improper, or erroneous purchases. The risk assessment team assigned a low risk level for these programs primarily because travel and fleet card transactions represented only about 3.1 percent and about 0.4 percent, respectively, of the approximately $4.4 billion VA spent on charge card transactions during FY 2017. The OIG continues to plan audits of VA’s charge card expenditures. The OIG Office of Investigations also continues to perform work on individual cases of purchase card abuse.________________________________________

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 Hudson Valley 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; 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 107 employees. The Facility has generally stable executive leadership and active engagement with employees and patients. Organizational leadership supports 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. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the most current “4-Star” rating. The OIG noted findings in three areas of clinical operations reviewed and issued six recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluations (2) Environment of Care • Attendance on environment of care rounds • Environmental cleanliness, safety, and infection control in patient care areas • Patient Safety in the Acute Mental Health Unit showers (3) Medication Management: Controlled Substances Inspection Program • Same-day completion of physical inventories of the controlled substance storage areas • Correction of deficiencies identified during annual physical security survey of the controlled substance storage areas

This report presents the results of our audit of the Bank Deposits – Brandywine, MD, Post Office. The Brandywine Post Office is in the Capital District of the Capital Metro Area. This audit was designed to provide U.S. Postal Service management with timely information on potential financial control risks at Postal Service locations. The objective of this audit was to determine whether financial differences related to bank deposits were properly researched and resolved at the Brandywine, MD, Post Office.

We determined that U.S. Immigration and Customs Enforcement (ICE) uses two types of inspections to examine detention facilities in more than 200 detention facilities, yet, neither the inspections nor the onsite monitoring ensure consistent compliance with detention standards, nor do they promote comprehensive deficiency corrections. Further, the ICE inspections, follow-up processes, and onsite monitoring of facilities help correct some deficiencies, however, they do not ensure adequate oversight or systemic improvements in detention conditions, with some deficiencies remaining unaddressed for years. We recommended that the detention inspection processes are revised with quality control measures to ensure the reported inspection results are thorough and accurate, as well as improving the follow-up process after identifying deficiencies. We made five recommendations to improve inspections, follow up, and monitoring of ICE detention facilities. ICE concurred with all recommendations, which remain resolved and open.