Federal Reports

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Semiannual Report to the Congress April 1, 2023 - September 30, 2023

This report summarizes work we initiated and completed during this semiannual period on a number of critical U.S. Department of Commerce (Department) activities. Over the past 6 months, our office issued 10 products related to our audit, evaluation, and inspection work. These products addressed programs and personnel associated with the U.S. Census Bureau, U.S. Economic Development Administration (EDA), National Oceanic and Atmospheric Administration (NOAA), National Telecommunications and Information Administration, United States Patent and Trademark Office, and the Department itself. This report also describes our investigative activities addressing programs and personnel associated with the Census Bureau, EDA, NOAA, and the Department.

Semiannual Report to Congress for the period April 1, 2023 – September 30, 2023

Without enforcing established access control requirements, the EPA puts the chemical data, which IRIS users rely upon to inform scientifically sound environmental regulations and policies, at risk of unauthorized changes.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that facility leaders failed to complete clinical and institutional disclosures for three identified patients. The OIG substantiated that one of the three patients received a delayed institutional disclosure and did not receive a clinical disclosure. The OIG found that the delay in the institutional disclosure occurred because the Chief of Staff established a process to have a peer review conducted prior to determining if an institutional disclosure was warranted. The other two patients received clinical disclosures.During the inspection, the OIG identified concerns related to deficiencies in quality management and safety processes, including failure to enter events into the Joint Patient Safety Reporting system and review adverse events, failure to initiate a required root cause analysis, and insufficient documentation and explanation of decision-making within Peer Review Committee meeting minutes. Additionally, the OIG determined that facility providers failed to properly communicate abnormal imaging and laboratory test results to patients as required by policy.The OIG made five recommendations to the Facility Director related to conducting and documenting clinical disclosures; evaluating quality management processes that impede the timeliness of conducting institutional disclosures; adhering to Peer Review Committee documentation standards; ensuring adverse events or close calls are entered into the system, reviewed, and required actions are conducted per policy; and evaluating the process for the communication of abnormal test results to patients.

The VA Office of Inspector General (OIG) conducted a national review to evaluate lung cancer screening (LCS) with low-dose computed tomography scan (CT scan) provided through the VA community care program.Lung cancer is the leading cause of cancer-related death in the United States. LCS with low-dose CT scan helps identify lung cancer prior to the development of symptoms. The US Preventive Services Task Force first recommended LCS in 2013 and updated the recommendation in 2021.The OIG surveyed 139 Veterans Health Administration (VHA) facilities. The OIG found that while VHA requires facilities that conduct LCS have an LCS coordinator and use a patient management tool/registry to track and manage patients, the same services are not required for community care LCS. Survey respondents identified the top five barriers to the management of community care low-dose CT consults.Through electronic health record reviews, the OIG found 11 VHA facilities with missing community care scan results. Fifty-seven percent of facilities had results that were not relayed to providers within 14 days of appointment completion. More importantly, 13 percent of facilities had abnormal results from the community that were not relayed to providers within 14 days.Thirty-six percent of facilities had patients that were not notified of community care low-dose CT scan results, 21 percent did not have documented patient notification within 14 days for normal results, and 4 percent within 7 days for abnormal results.Thirty-seven percent of facilities had patients that did not have one-year follow-up scans ordered and 23 percent did not have a scheduled follow-up appointment for abnormal results. The OIG found seven patients with abnormal scan results did not receive follow-up per recommendations.The OIG made five recommendations to the Under Secretary for Health related to timely and quality screening for patients who depend on community care LCS.