Federal Reports

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 Puget Sound Health Care System (the 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 75 employees. The Facility’s leadership team is relatively new. With the exception of the Acting Assistant Director, the executive leaders have been working together as a team since October 2017. 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 OIG’s review of survey data suggested generally satisfied employees, opportunities appear to exist to improve outpatient experiences. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance likely contributing to the two-star ranking. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Director, Chief of Staff, Deputy Director, and Assistant Director. The identified areas with deficiencies are: (1) Environment of Care • Environment of care rounds attendance • Medical equipment safety • Infection Prevention Committee’s discussion and documentation of on-going construction activities • Temperature monitoring in dry food storage areas (2) Medication Management: Controlled Substances Inspection Program • Reconciliation of controlled substances dispensing and return of stock

The OIG's Field Financial Risk Model identified the Eatontown, NJ, Post Office made a total of $20,773, or 36 percent, of all local purchases and payments within the South Jersey District. During our review, we identified the Eatontown Post Office had an additional $2,000 of local purchases and payments. These payments were made using no-fee money orders (NFMO) from July 1, 2017 through December 31, 2017. The objective of this audit was to determine whether local purchases and payments were valid and properly supported.

We conducted an audit to evaluate controls over the Working Capital Fund in FY 2016. Specifically, we sought to determine whether (1) there were effective controls over the billing and algorithm development processes, (2) relationships of reimbursements and billings to services provided were reasonable, (3) projects utilized performance metrics as management tools to assess project performance, (4) projects’ funding levels were adequately supported, and (5) the Office of the Secretary Office of Financial Management Directorate had effective controls over retaining or returning advances received in excess of obligations.

The OIG audited the costs claimed by the State of Nebraska’s Game and Parks Commission, under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program. The audit included claims totaling $46.9 million on 115 grants that were open during the State fiscal years that ended June 30, 2015, and June 30, 2016. The audit also covered the Commission’s compliance with applicable laws, regulations, and FWS guidelines, including those related to the collection and use of hunting and fishing license revenues and reporting program income.We found that the Commission complied with applicable grant accounting and regulatory requirements. We observed that the Commission classified its Wildlife and Sportfish Restoration Program service and cooperative agreements as contracts when they should have been classified as subawards. Based on our audits of other states and, following discussions with Commission and FWS staff, we believe additional Program guidance is needed concerning the determination of subawards and contracts. Therefore, we did not issue a formal recommendation in this final audit report. We will address the issue directly with FWS in a separate report.

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U.S. Postal Service tort claims are claims for damage to or loss of property, or claims for personal injury or death to non-Postal Service personnel caused by the negligent or wrongful act or omission of an employee acting within the scope of his or her employment. The objective was to assess the effectiveness of controls over paid tort claims in the Postal Service's Western Area.