Federal Reports

We engaged with an independent public accounting (IPA) firm to audit DIA's FY 2023 financial statements. We evaluated the reliability of data supporting the financial statements, determined the reasonableness of the statements produced, and examined disclosures in accordance with applicable guidance.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the quality of care provided during a patient’s hospitalization, which ended with the patient’s death at the Lt. Col. Luke Weathers, Jr. VA Medical Center (facility) in Memphis, Tennessee. The OIG also evaluated facility leaders’ response to the patient’s care.A telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a blue alert, which may have affected the patient’s outcome. A charge nurse’s failure to assign a nurse to care for the patient or provide accurate nursing assignments to the telemetry technician may have also contributed to the delay. Additionally, an intensive care unit fellow did not document a response to a critical care consult and did not recall the patient, rendering the OIG unable to determine the clinical decision-making rationale.Facility leaders’ factfinding and root cause analysis reviews of the patient’s care were not thorough, which hindered identification of systemic and causal factors. Contributing factors included a nursing leader who did not issue an authorization letter to provide the factfinding investigator guidance on the focus of the review, and the root cause analysis team who did not interview some staff directly involved with the patient event, as required.The OIG made five recommendations to the Facility Director related to compliance with the cardiac telemetry monitoring policy, making and communicating nursing assignments, documenting critical care consults, conducting factfindings and root cause analyses, and consideration of another root cause analysis.

The Cybersecurity and Infrastructure Security Agency (CISA) had extensive products and services to manage risks and mitigate cybersecurity threats to critical water and wastewater infrastructure and increase its resiliency. However, CISA did not consistently collaborate with the Environmental Protection Agency and the Water and Wastewater Systems Sector to leverage and integrate its cybersecurity expertise with stakeholders’ water expertise.

During fiscal years 2018 through 2022, we issued 61 reports and 178 recommendations for improving conditions at the Southwest border. As of August 17, 2023, 144 recommendations were closed, 31 recommendations were resolved and open, and 3 recommendations remained unresolved.