Federal Reports

How does PBGC measure up in the area of IT security? This information-only report provides a summary and analysis of the Pension Benefit Guaranty Corporation's progress in remediating IT audit recommendations, as well as its FISMA performance in general and its FISMA performance in comparison to other federal agencies. Bottom line: PBGC has made progress in IT security in the past five years. In FISMA performance, PBGC ranks as average among small agencies in one comparison and above average in another.

We investigated approximately $10 million in unsupported payments that were made to the Indian Pueblos Federal Development Corporation (IPFDC) and its partners, pursuant to IPFDC’s contract to develop and construct the Bureau of Indian Affairs (BIA) and Bureau of Indian Education buildings in Albuquerque, NM. Our investigation determined that former IPFDC President and Chief Executive Officer Bruce Sanchez and New Mexico real estate owner Thomas Keesing stole over $3.5 million from the IPFDC between 2004 and 2008, by falsifying invoices for services that Keesing claimed he provided as a contractor for the IPFDC, including services on the two BIA buildings. Keesing then shared the proceeds of the fraudulently obtained payments with Sanchez.Sanchez pled guilty in the Federal District of New Mexico to embezzlement and attempted tax evasion and was sentenced to 51 months in prison. Keesing pled guilty to embezzlement and failure to file taxes and was sentenced to 35 months in prison. Sanchez and Keesing were also ordered to jointly repay $3,575,000 and were debarred from Federal contracts for 3 years.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Memphis 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; 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 183 employees. The Facility appears to have stable executive leadership that needs to improve patient satisfaction. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results identified recent delivery of poor care and substantial future organizational risks if improvements are not made. The senior leaders should take actions to improve care and performance of SAIL metrics (Quality of Care and Efficiency) likely contributing to the current “1-Star” rating. The OIG noted findings in six areas reviewed and issued 13 recommendations attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value• Documentation of patient safety incidents in WebSPOT database(2) Credentialing and Privileging• Focused and Ongoing Professional Practice Evaluation processes(3) Environment of Care• Attendance of environment of care rounds• Safety and cleanliness of patient care areas• Contamination prevention in equipment storage areas• CBOC medication safety and means of egress• Cleanliness of food service and storage areas(4) Medication Management: Controlled Substances Inspection Program• Completion of annual Controlled Substances Inspector training(5) Long-Term Care: Geriatric Evaluations• Program evaluation and performance improvement(6) High-Risk Processes: Central Line-Associated Bloodstream Infections• Staff training