Federal Reports

We audited costs claimed by the New Hampshire Fish and Game Department under grants awarded by the FWS through WSFR.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that staff delayed providing intervention and care for a patient who died following a medical emergency at a VA outpatient clinic. The OIG identified issues related to quality of care and the facility response.The OIG substantiated that a nurse delayed initiating cardiopulmonary resuscitation (CPR) after establishing the patient did not have a pulse and was not breathing, but was unable to determine if the delay led to the patient’s death. The OIG determined that failures in response to the medical emergency included ineffective emergency notification speakers to activate the emergency response, and incomplete incident documentation and review.During the inspection, the OIG identified concerns related to the quality of care provided to the patient in the days prior to and at the time of the incident that presented potential opportunities for additional assessment of the patient’s symptoms. Additional concerns included leaders’ response to the incident and staffs’ knowledge of the processes in place for advance healthcare planning with patients. The OIG found that in response to the incident, facility leaders conducted an emergency management debrief and completed an after-action review. However, facility leaders’ reviews of the incident were limited by a lack of information documented in the EHR, and decisions made based upon an unconfirmed determination of the patient’s cause of death.The OIG made five recommendations to the Facility Director related to ensuring proper outpatient clinic emergency processes including staff training, emergency notification, and documentation; ensuring compliance with CPR documentation; monitoring after-action plans for completion and compliance; consulting with the Office of General Counsel’s Regional Counsel to determine if an institutional disclosure is warranted; and evaluating and addressing staff’s understanding of advance care planning.

On August 24, 2021, the Peace Corps notified the United States Congress that Peace Corps/Dominican Republic (hereafter referred to as “the post”) intended to resume operations in December 2021. The first intake arrived in March 2022 with 13 Volunteers, including 2 reinstated Volunteers. On September 29, 2022, the Office of Inspector General announced this review to assess the post’s compliance with specific agency policies and procedures related to Volunteer and trainee health and safety, and the re-entry process.

On May 11, 2021, the U.S. Environmental Protection Agency Office of Inspector General,Administrative Investigations Directorate initiated an investigation into potentially improperexpenditures made by Dr. Katherine A. Lemos. The purpose of theinvestigation was to determine whether Dr. Lemos (1) improperly used Board funds for travelfrom her residence in San Diego to her official duty station in Washington, D.C.; (2) exceededthe statutory cap on expenses for her office refurbishment; and (3) hired two senior aides on anoncompetitive basis.

The Washington NDC is a highly mechanized U.S. Postal Service mail processing plant that distributes standard mail and packages in piece and bulk form. To carry out its mission, the Washington NDC owns the following types of assets:Capital assets have a unit cost of $10,000 or more, are acquired through purchase, transfer, or donation, and depreciate. In calendar year 2014, the threshold for capital assets was increased from $3,000 to $10,000.Expendable assets cost less than $10,000 and include items such as repair parts, replacement components, mail transport equipment, and workroom furniture. Sensitive assets are a subcategory of expendable assets and consist of assets vulnerable to theft or loss, and include items such as computers, laptops, cell phones, digital cameras, and other valuable portable equipment. Assets can be stored onsite in internal stockrooms or outside in storage facilities. Washington NDC management utilizes a 6,375 square feet external portable structure – built in 1995 – to store equipment and repair parts that exceed the storage capacity of its internal stockroom.