Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Oscar G. Johnson VA Medical Center, which includes multiple outpatient clinics in Michigan and Wisconsin. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued three recommendations for improvement in two areas:1. Leadership and organizational risks• Identification of sentinel events for home oxygen fires• Veterans Integrated Service Network tracking and monitoring of root cause analyses2. Mental health• Completion of Comprehensive Suicide Risk Evaluations

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Maine Healthcare System, which includes the Togus VA Medical Center and multiple outpatient clinics in Maine. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued 12 recommendations for improvement in all five areas:1. Leadership and organizational risks• Sentinel events and institutional disclosures2. Quality, safety, and value• Root cause analysis for patient safety events3. Medical staff privileging• Ongoing Professional Practice Evaluation data• Focused Professional Practice Evaluation reporting• VISN oversight of credentialing and privileging processes4. Environment of care• Environment of care inspections• Panic and over-the-door alarm testing• Maintaining a safe environment• Hazard warning signs• Safe and clean patient care areas5. Mental health• Comprehensive Suicide Risk Evaluation completion

An Amtrak Assistant Passenger Conductor based in Philadelphia violated company policy by altering her company paystub for July 2022 and submitting it to a financial institution for the purpose of securing a mortgage loan. On April 2, 2024, the employee received a final warning after she waived her right to a hearing and accepted responsibility for the charges.

The Office of Inspector General (OIG) is issuing this inspection report to present the results of our assessment of the U.S. Small Business Administration’s (SBA) initial response to the Maui wildfire disaster, including staffing, loan application volume, and timeliness of disaster loan approvals. We found SBA’s initial response to the Maui wildfire disaster was timely and effective. On the day of the Presidential disaster declaration, SBA placed personnel in locations throughout Hawaii to support businesses and residents impacted by the wildfires. Within 6 days of the Presidential disaster declaration, SBA representatives were stationed at the first Disaster Recovery Center and Business Recovery Center on Maui and provided timely disaster loan assistance to survivors.While SBA successfully navigated disaster assistance challenges such as increased customer service calls and loan applications, we identified an opportunity for improvement that may be beneficial in future disasters – specifically, a standard way to quickly adjust staffing levels as the volume of activity shifts at each center. We suggested SBA management routinely conduct a staffing needs assessment throughout a disaster to ensure recovery centers are adequately staffed based on customer demand and workload.SBA management disagreed with our suggestion and stated that SBA regularly examines staffing levels and will continue to do so as it navigates future disaster assistance challenges. Management further stated that a new system is not needed because of the existing system that is in place.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Central Iowa Health Care System, which includes the Des Moines VA Medical Center and multiple outpatient clinics in Iowa. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued three recommendations for improvement in two areas:1. Medical staff privileging• Ongoing Professional Practice Evaluations by providers with equivalent specialized training and similar privileges• Ongoing Professional Practice Evaluation activities2. Mental health• Comprehensive Suicide Risk Evaluation completion

As required by the Inspector General Act of 1978 (as amended), this Semiannual Report summarizes the activities of the Department of Transportation Office of Inspector General for the preceding 6-month period.

OIG reviewed the Forest Service to determine the likely level of sophistication an attacker would need to compromise selected USDA systems or data. OIG made one recommendation to FS and reached management decision on it.

2024 Peer Review Results of the Office of the Inspector General for the U.S. Nuclear Regulatory Commission and Defense Nuclear Facilities Safety Board, Investigations Division